Individual
JORDAN M WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
2002 S 11TH ST, NILES, MI 49120-4074
(269) 687-0200
(269) 684-0199
Mailing address
6416 DEANS HILL RD, BERRIEN CENTER, MI 49102-9750
(269) 471-7741
(269) 471-1581
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
5601005116
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1831383074
—
MI
Enumeration date
08/30/2007
Last updated
03/14/2013
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