Individual
MICHAEL J WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
450 BROOKLINE AVE, BOSTON, MA 02215-5450
(617) 632-5204
(617) 632-3408
Mailing address
450 BROOKLINE AVE, BOSTON, MA 02215-5450
(617) 632-5204
(617) 632-3408
Taxonomy
Speciality
Code
Description
License number
State
207RX0202X
Medical Oncology Physician
Primary
1016422
MA
207RX0202X
Medical Oncology Physician
MD60759395
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1023317898
—
WA
01
—
G8968128
MEDICARE PIN
WA
Enumeration date
03/19/2011
Last updated
10/19/2023
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