Individual
JACOB WAGNER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
2450 RIVERSIDE AVE, MINNEAPOLIS, MN 55454-1450
(612) 672-6000
Mailing address
2450 RIVERSIDE AVE, MINNEAPOLIS, MN 55454-1450
(612) 672-6000
(612) 624-3189
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
11018250A
IN
207R00000X
Internal Medicine Physician
Primary
67426
MN
208000000X
Pediatrics Physician
01082119A
IN
208000000X
Pediatrics Physician
67426
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
201297560
—
IN
Enumeration date
06/02/2015
Last updated
11/22/2022
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