DYLAN PAUL WAGNER (NPI# 1992058556) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1992058556 |
| Entity Type | Individual |
| Full Name | DYLAN PAUL WAGNER |
| Credential | PA |
| Practice Address |
2313 Highway 15 N Laurel MS 39440-1805 |
| Mailing Address |
415 S 28th Ave Hattiesburg MS 39401-7246 |
| Practice Telephone | 6016492775 |
| Practice Fax Number | 6016492686 |
| Mailing Telephone | 6016492775 |
| Mailing Fax Number | 6015795240 |
| Enumeration Date | 2012-10-19 |
| Last Update Date | 2020-07-23 |
| Gender Code | M |
| Is Sole Proprietor | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| Y | 363AM0700X |
Physician Assistant Specialization: Medical |
00172 | MS | Physician Assistants & Advanced Practice Nursing Providers |
| State | Issuer | Identifier | Type Code |
|---|---|---|---|
| MS | 05153323 | 05 | |
| MS | CIGNA | 5874982 | 01 |
| MS | UNITED HEALTHCARE | 3528936 | 01 |
| MS | AETNA | 9469937 | 01 |
| Street Address |
2313 HIGHWAY 15 N |
| City | LAUREL |
| State | MS |
| Zip Code | 39440-1805 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1427095579 | Chrystal A Sumrall | Family Medicine | 2313 Highway 15 N, Laurel, MS 39440-1805 | 2006-05-31 |
| 1477864585 | Charles Erickson Probst | Family Medicine | 2313 Highway 15 N, Laurel, MS 39440-1805 | 2010-06-24 |
| 1659508612 | Deborah Darlene Stonefield | Nurse Practitioner | 2313 Highway 15 N, Laurel, MS 39440-1805 | 2009-06-17 |
| 1366686354 | Frank Eugene Dement IIi | Pediatrics | 2313 Highway 15 N, Laurel, MS 39440-1805 | 2009-04-22 |
| 1316047657 | Hattiesburg Clinic Pa | Family Medicine | 2313 Highway 15 N, Laurel, MS 39440-1805 | 2006-09-25 |
| 1952414583 | Larry T Holifield | Family Medicine | 2313 Highway 15 N, Laurel, MS 39440-1805 | 2006-08-17 |
| 1861417065 | Roger T Lott | Family Medicine | 2313 Highway 15 N, Laurel, MS 39440-1805 | 2006-07-12 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1306323159 | Tender Loving Care Homecare LLC | Homemaker | 509 Central Ave Ste 224, Laurel, MS 39440 | 2018-07-24 |
| 1669837910 | Laurel Dental Properties | Dentist | 1925 Pine Belt Drive, Laurel, MS 39440 | 2015-12-30 |
| 1215282991 | South Central Regional Medical Center | Clinic/Center | 525 Wayne Drive, Laurel, MS 39440 | 2012-07-18 |
| 1568721215 | Terry Ratcliff Perkins | Counselor | 5192 Hwy 11 North, Laurel, MS 39440 | 2012-05-15 |
| 1437453057 | Alexander Milne Home for Women | Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities | 616 East 19th Street, Laurel, MS 39440 | 2010-12-23 |
| 1710135629 | Jeffrey R. Moffett | Nurse Practitioner | 3115 Audubon Dr, Laurel, MS 39440 | 2008-09-04 |
| 1003096785 | Family Health Center, Inc | Obstetrics & Gynecology | 103 S. 12th Avenue, Laurel, MS 39440 | 2007-11-09 |
| 1669672143 | Laurel Urology Clinic Pa | Urology | 304 S 10th Ave, Laurel, MS 39440 | 2007-07-23 |
| 1093912370 | Tanweer Hussain Majid | Surgery | 1007 Jefferson Street, Laurel, MS 39440 | 2007-06-29 |
| 1780889923 | Hattiesburg Eye Clinic, Pa | Ophthalmology | 1431 North 10th St, Suite 1, Laurel, MS 39440 | 2007-06-18 |
| Find all providers in zip 39440 | ||||
| Taxonomy Code | 363AM0700X |
| Grouping | Physician Assistants & Advanced Practice Nursing Providers |
| Classification | Physician Assistant |
| Specialization | Medical |
| Definition to come... |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1780944892 | Shamane I Onwudiachi | Physician Assistant | 805 Washington Blvd S, Laurel, MD 20707-4611 | 2012-05-22 |
| 1760786172 | Haileleoul Desta Erbello | Physician Assistant | 8118 Gorman Ave, Apt # 104, Laurel, MD 20707 | 2010-12-28 |
| 1710974290 | Dawn A. Adams | Physician Assistant | 7300 Van Dusen Rd, Laurel, MD 20707-9463 | 2005-09-30 |
| 1720441355 | Tiffany Edwards Keith | Physician Assistant | 1220 Jefferson St, Laurel, MS 39440-4355 | 2016-03-31 |
| 1386018414 | Eric Christopher Huber | Physician Assistant | 3357b Corridor Marketplace, Laurel, MD 20724-2381 | 2015-12-01 |
| 1740675487 | Alan Bryson | Physician Assistant | 1440 Jefferson St, Laurel, MS 39440-4243 | 2015-03-31 |
| 1942549027 | Olabisi Oladapo | Physician Assistant | 3357b Corridor Marketplace, Laurel, MD 20724-2381 | 2013-02-08 |
| 1710127741 | Emerson Yang Chang | Physician Assistant | 7350 Van Dusen Rd, Suite 130, Laurel, MD 20707-5263 | 2009-03-03 |
| 1558522334 | Amy Elaine Reisman | Physician Assistant | 7300 Van Dusen Rd, Laurel, MD 20707-9463 | 2008-06-24 |
| 1740294669 | Beth L Pascal | Physician Assistant | 575 Main St, 351, Laurel, MD 20707-4343 | 2006-07-28 |
| Find all providers in LAUREL | ||||
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.