Mark Darrel Wagner

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

30642 Issued in MN

Practice address

1120 E 34TH St
Hibbing, MN 55746-2909

Phone

(218) 362-7100

Fax

(218) 362-7131

NPI assigned

Nov 20, 2006

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Electronic endpoints 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1163980800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1607040000000",
    "number": "1942374210",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1120 E 34TH ST",
            "city": "HIBBING",
            "state": "MN",
            "postal_code": "557462909",
            "telephone_number": "218-362-7100",
            "fax_number": "218-362-7131"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1120 E 34TH ST",
            "city": "HIBBING",
            "state": "MN",
            "postal_code": "557462909",
            "telephone_number": "218-362-7100",
            "fax_number": "218-362-7131"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WAGNER",
        "first_name": "MARK",
        "middle_name": "DARREL",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-11-20",
        "last_updated": "2020-12-04",
        "certification_date": "2020-12-04",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MN",
            "license": "30642",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "701083400",
            "state": "MN"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "him@slk.direct.slhduluth.com",
            "affiliation": "N",
            "address_1": "1120 E 34th St",
            "city": "Hibbing",
            "state": "MN",
            "country_code": "US",
            "postal_code": "557462909",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Vista Eye Exam
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• Nicole Marie Vlasich, LICSW
• Kristal Ruth Waara
• Krista Kate Wagner, OTR
• Wal-Mart Stores, Inc.
• Walgreen Co
• Colleen Rae Wallis, P.A.C.
• Walmart Inc.
• Katelyn Ashley Wamhoff, LICSW

• Family Medicine Physician in Hibbing, MN
• Providers in Hibbing, MN by specialty
• Family Medicine Physician in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 4, 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.

Verify at the official NPI Registry.