Provider Demographics
NPI:1447330741
Name:WAGNER, MITCHELL (MD)
Entity type:Individual
Prefix:
First Name:MITCHELL
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 1:520 ROSE LN
Mailing Address - Street 2:
Mailing Address - City:WICKENBURG
Mailing Address - State:AZ
Mailing Address - Zip Code:85390-1447
Mailing Address - Country:US
Mailing Address - Phone:928-684-4365
Mailing Address - Fax:928-684-2434
Practice Address - Street 1:520 ROSE LN
Practice Address - Street 2:
Practice Address - City:WICKENBURG
Practice Address - State:AZ
Practice Address - Zip Code:85390-1447
Practice Address - Country:US
Practice Address - Phone:928-684-4365
Practice Address - Fax:928-684-2434
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27272207X00000X, 207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ457920Medicaid
AZAZ0866130OtherBCBS
AZ7878067OtherAETNA
AZ457920Medicaid