Provider Demographics
NPI:1053340588
Name:WAGNER, SCOTT BRIAN (DC)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:BRIAN
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2109 INDIA RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901-2886
Mailing Address - Country:US
Mailing Address - Phone:434-978-4888
Mailing Address - Fax:434-978-3633
Practice Address - Street 1:2109 INDIA RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901-2886
Practice Address - Country:US
Practice Address - Phone:434-978-4888
Practice Address - Fax:434-978-3633
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104555923111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician