Provider Demographics
NPI:1770749541
Name:WAGNER, EARL JASON (SUBMARINE IDC)
Entity type:Individual
Prefix:
First Name:EARL
Middle Name:JASON
Last Name:WAGNER
Suffix:
Gender:M
Credentials:SUBMARINE IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 HICKORY DR
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-2910
Mailing Address - Country:US
Mailing Address - Phone:860-449-9359
Mailing Address - Fax:
Practice Address - Street 1:USS PITTSBURGH SSN-720
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09582-2400
Practice Address - Country:US
Practice Address - Phone:860-694-3618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-31
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman