Individual
JOHN S WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.C.
Contact information
Practice address
3778 UNION ST, LAFAYETTE, IN 47905-4453
(765) 448-1674
Mailing address
3778 UNION ST, LAFAYETTE, IN 47905-4453
(765) 448-1674
Taxonomy
Speciality
Code
Description
License number
State
111N00000X
Chiropractor
Primary
08000532A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000197485
BLUE CROSS/BLUE SHIELD
IN
05
—
100262580
—
IN
Enumeration date
11/09/2005
Last updated
01/02/2015
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