Provider Demographics
NPI:1144704925
Name:WAGNER, MITCHELL JOHN (DC)
Entity type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:JOHN
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 13TH AVE NE STE B002C
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-1091
Mailing Address - Country:US
Mailing Address - Phone:612-879-8000
Mailing Address - Fax:
Practice Address - Street 1:34 13TH AVE NE STE B002C
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-1091
Practice Address - Country:US
Practice Address - Phone:612-879-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6461111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6461OtherN/A