Individual
MARK T. WAGNER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
1248 KINNEYS LN, PORTSMOUTH, OH 45662-2994
(740) 356-7290
(740) 356-7938
Mailing address
1735 27TH ST STE B06, PORTSMOUTH, OH 45662-2681
(740) 356-8681
(740) 353-7900
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
34003690W
OH
207Q00000X
Family Medicine Physician
Primary
34.003690
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0557642
—
OH
Enumeration date
03/14/2007
Last updated
09/26/2022
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