Provider Demographics
NPI:1801858832
Name:WAGNER, IAN ROBERT (DC)
Entity type:Individual
Prefix:DR
First Name:IAN
Middle Name:ROBERT
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 1:804 BETHANY DR
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15243-1620
Mailing Address - Country:US
Mailing Address - Phone:412-276-0237
Mailing Address - Fax:
Practice Address - Street 1:421 COCHRAN RD
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15228-1255
Practice Address - Country:US
Practice Address - Phone:412-531-8701
Practice Address - Fax:412-531-8703
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC007583L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAU75882Medicare UPIN
PA028752RDLMedicare ID - Type Unspecified