Basic Information
| Provider Information | |||||||||
| NPI: | 1326033572 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | CRAIG | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO ANESTHESIOLOGIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 509 N BROAD ST | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080961617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568450100 | ||||||||
| FaxNumber: | 8568487023 | ||||||||
| Practice Location | |||||||||
| Address1: | 509 N BROAD ST | ||||||||
| Address2: | UNDERWOOD HOSP | ||||||||
| City: | WOODBURY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568455836 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2005 | ||||||||
| LastUpdateDate: | 07/15/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | N | Other Service Providers | Specialist | 207L00000X | 25MB05214300 | NJ | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1442007 | 05 | NJ | MEDICAID | 25MB05214300 | 01 | NJ | MEDICAL LICENSE | OTHER | BW1551933 | 01 | DEA | OTHER | D04881500 | 01 | NJ | CDS | OTHER |