Individual
DOUGLAS LEE WAGONER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1805 HENNEPIN AVE N, GLENCOE REGIONAL HEALTH SERVICES, GLENCOE, MN 55336-1416
(320) 864-3121
(320) 864-7887
Mailing address
1805 HENNEPIN AVE N, GLENCOE, MN 55336-1416
(320) 864-3121
(320) 864-7887
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
27782
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
024767000
—
MN
Enumeration date
10/13/2005
Last updated
11/25/2020
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