Individual
JOHN WAGNER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
7330 FERN AVE STE 704, SHREVEPORT, LA 71105-4985
(318) 798-8261
(316) 798-8263
Mailing address
7330 FERN AVE STE 704, SHREVEPORT, LA 71105-4985
(318) 798-8261
(316) 798-8263
Taxonomy
Speciality
Code
Description
License number
State
2084P0804X
Child & Adolescent Psychiatry Physician
Primary
MD.201230
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1214841
—
LA
01
—
4P278F600
MEDICARE - PTAN
LA
Enumeration date
05/25/2007
Last updated
05/22/2019
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