Provider Demographics
NPI:1861179665
Name:WAGNER, FREDERICK WILLIAM III (MED)
Entity type:Individual
Prefix:MS
First Name:FREDERICK
Middle Name:WILLIAM
Last Name:WAGNER
Suffix:III
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 JONES ST
Mailing Address - Street 2:
Mailing Address - City:SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-2914
Mailing Address - Country:US
Mailing Address - Phone:929-483-7383
Mailing Address - Fax:
Practice Address - Street 1:19 JONES ST
Practice Address - Street 2:
Practice Address - City:SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-2914
Practice Address - Country:US
Practice Address - Phone:929-483-7383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-03
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2512521174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty