Provider Demographics
NPI:1861053050
Name:WAGNER, WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 W 200 N STE 200
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-7386
Mailing Address - Country:US
Mailing Address - Phone:435-986-2020
Mailing Address - Fax:435-652-1516
Practice Address - Street 1:161 W 200 N STE 200
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-7386
Practice Address - Country:US
Practice Address - Phone:435-986-2020
Practice Address - Fax:435-652-1516
Is Sole Proprietor?:No
Enumeration Date:2019-06-27
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE8641207W00000X
OH35.147743207W00000X
390200000X
UT13858841-1205207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program