Provider Demographics
NPI:1871696914
Name:WAGGENER, MARK W (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:WAGGENER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:7866 9TH STREET CIR N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-5347
Mailing Address - Country:US
Mailing Address - Phone:651-735-7946
Mailing Address - Fax:
Practice Address - Street 1:1575 BEAM AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1126
Practice Address - Country:US
Practice Address - Phone:651-232-7348
Practice Address - Fax:651-232-6665
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2011-08-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN46143207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN926495700Medicaid