Individual
MR. PHILIP WAGENBACH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
275 ROUTE 30 N, BOMOSEEN, VT 05732-9647
(802) 468-5641
(802) 468-2923
Mailing address
700 SCHOOL ST, PAWTUCKET, RI 02860-5747
(401) 616-2000
(401) 616-2001
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
001695
CT
363AM0700X
Medical Physician Assistant
Primary
055-0031268
VT
Other
Enumeration date
08/13/2006
Last updated
10/05/2015
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