Active NPI
Douglas Lee Wagoner, MD
- Family Medicine Physician
- Glencoe, MN
National Provider Identifier
1225027162
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- 27782
- Practice address
- 1805 Hennepin Ave N
Glencoe Regional Health Services
Glencoe, MN 55336-1416 - Phone
- (320) 864-3121
- Fax
- (320) 864-7887
- NPI assigned
- Oct 13, 2005
- Last updated
- Nov 25, 2020
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 27782 | MN | Primary |
Addresses
Primary practice location
1805 Hennepin Ave N
Glencoe Regional Health Services
Glencoe, MN 55336-1416
Mailing address
1805 Hennepin Ave N
Glencoe, MN 55336-1416
Phone (320) 864-3121
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 024767000 | Medicaid | MN |
Electronic endpoints 1
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| Direct Messaging Address | dwagoner83502@excellian.direct.allina.com | Direct |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
Interoperability endpoints
- dwagoner83502@excellian.direct.allina.com
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1129161600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1606262400000",
"number": "1225027162",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1805 HENNEPIN AVE N",
"city": "GLENCOE",
"state": "MN",
"postal_code": "553361416",
"telephone_number": "320-864-3121",
"fax_number": "320-864-7887"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1805 HENNEPIN AVE N",
"address_2": "GLENCOE REGIONAL HEALTH SERVICES",
"city": "GLENCOE",
"state": "MN",
"postal_code": "553361416",
"telephone_number": "320-864-3121",
"fax_number": "320-864-7887"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WAGONER",
"first_name": "DOUGLAS",
"middle_name": "LEE",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2005-10-13",
"last_updated": "2020-11-25",
"certification_date": "2020-11-25",
"status": "A"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "MN",
"license": "27782",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "024767000",
"state": "MN"
}
],
"endpoints": [
{
"endpointType": "DIRECT",
"endpointTypeDescription": "Direct Messaging Address",
"endpoint": "dwagoner83502@excellian.direct.allina.com",
"affiliation": "N",
"use": "DIRECT",
"useDescription": "Direct",
"contentType": "OTHER",
"contentTypeDescription": "Other",
"contentOtherDescription": "CDA/PDF/TXT",
"address_1": "1805 Hennepin Ave N",
"address_2": "Glencoe Regional Health Services",
"city": "Glencoe",
"state": "MN",
"country_code": "US",
"postal_code": "553361416",
"country_name": "United States",
"address_type": "DOM"
}
],
"other_names": []
}Other providers in Glencoe, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 25, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.