Provider Demographics
NPI:1902051501
Name:WAGNER, VERN ALAN
Entity Type:Individual
Prefix:
First Name:VERN
Middle Name:ALAN
Last Name:WAGNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:WOMACK ARMY MEDICAL CTR
Mailing Address - Street 2:BLDG 4-2817 REILLY ROAD
Mailing Address - City:FORT BRAGG
Mailing Address - State:NC
Mailing Address - Zip Code:28310-0001
Mailing Address - Country:US
Mailing Address - Phone:910-988-0188
Mailing Address - Fax:
Practice Address - Street 1:417 REILLY RD
Practice Address - Street 2:BLDG 4-217
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310
Practice Address - Country:US
Practice Address - Phone:910-907-8269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-24
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant