Provider Demographics
NPI:1164456430
Name:VANWAGNER, WILLIAM (PA-C)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:
Last Name:VANWAGNER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEEDS
Mailing Address - State:MA
Mailing Address - Zip Code:01053-9764
Mailing Address - Country:US
Mailing Address - Phone:413-582-3010
Mailing Address - Fax:413-582-3185
Practice Address - Street 1:421 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LEEDS
Practice Address - State:MA
Practice Address - Zip Code:01053-9764
Practice Address - Country:US
Practice Address - Phone:413-582-3010
Practice Address - Fax:413-582-3185
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1350363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant