Individual
DYLAN PAUL WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
2313 HIGHWAY 15 N, LAUREL, MS 39440-1805
(601) 649-2775
(601) 649-2686
Mailing address
415 S 28TH AVE, HATTIESBURG, MS 39401-7246
(601) 649-2775
(601) 579-5240
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
00172
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
05153323
—
MS
01
—
3528936
UNITED HEALTHCARE
MS
01
—
5874982
CIGNA
MS
01
—
9469937
AETNA
MS
Enumeration date
10/19/2012
Last updated
07/23/2020
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