Individual
JERAD SCOTT WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
921 14TH AVE NW, ARDMORE, OK 73401-1837
(580) 223-5311
(580) 223-8227
Mailing address
921 14TH AVE NW, ARDMORE, OK 73401-1837
(580) 223-5311
(580) 223-8227
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
2197
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2197
PHYSICIAN ASSISTANT LICENSE
OK
Enumeration date
02/05/2013
Last updated
01/27/2016
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