Individual
DR. ETHAN E WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
2015 JACKSON ST, ANDERSON, IN 46016-4337
(765) 646-8439
(765) 646-8578
Mailing address
2015 JACKSON ST, ANDERSON, IN 46016-4337
(765) 646-8439
(765) 646-8578
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
02002898A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000514519
BLUE CROSS /ANTHEM
IN
Enumeration date
07/20/2005
Last updated
10/10/2007
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