Wagoner, Jack

Wagoner, Jack is an individual health care provider with primary practice located at 205 N East Ave , Jackson MI 49201-1753. He recently has only one registered license in Allopathic & Osteopathic Physicians / Anesthesiology, which is considered as his primary health care specialty. Wagoner, Jack can be contacted via phone (517) 788-4963.

Contact Information

Primary practice address
205 N East Ave Jackson MI 49201-1753
Phone: (517) 788-4963
Fax: (517) 789-5903
Website:
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Health care specialties

SpecialtyCodeLicense #State
Allopathic & Osteopathic Physicians / Anesthesiology 207L00000X 4301-407025 Michigan

Profile Details

NPI number 1598700072
LBN Legal business name Wagoner, Jack
Credentials Doctor of Medicine (MD)
Entity Individual
Sole proprietor 1 No
Enumeration date Jun 18th, 2006
Last updated Nov 6th, 2007 - about 19 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1598700072 NPPES
Michigan MEDICAID 2737106

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