Dylan Paul Wagner, PA

Primary specialty

Medical Physician AssistantTaxonomy code 363AM0700X

License

00172 Issued in MS

Practice address

2313 Highway 15 N
Laurel, MS 39440-1805

Phone

(601) 649-2775

Fax

(601) 649-2686

NPI assigned

Oct 19, 2012

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 4

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in MS

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Physician Assistant

Education

Other, 2012

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Hattiesburg Clinic PAGroup PAC ID 5193706794, 525 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: dwagner20669@directpatientrecord.com

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Hattiesburg Clinic PA

  • Multi-Specialty Clinic/Center
  • Hattiesburg, MS
  • NPI 1740213446
  Medicare reassignment Care Compare group NPD
• Hattiesburg Clinic, PA

  dba Flowood Primary Care

  • Primary Care Clinic/Center
  • Flowood, MS
  • NPI 1912600354
  NPD
• State of Mississippi - University of Mississippi Medical Center

  dba Holmes County Hospital and Clinic

  • Critical Access Hospital
  • Lexington, MS
  • NPI 1386630705
  NPD (past)

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

{
    "created_epoch": "1350604800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1595462400000",
    "number": "1992058556",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "415 S 28TH AVE",
            "city": "HATTIESBURG",
            "state": "MS",
            "postal_code": "394017246",
            "telephone_number": "601-649-2775",
            "fax_number": "601-579-5240"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2313 HIGHWAY 15 N",
            "city": "LAUREL",
            "state": "MS",
            "postal_code": "394401805",
            "telephone_number": "601-649-2775",
            "fax_number": "601-649-2686"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WAGNER",
        "first_name": "DYLAN",
        "middle_name": "PAUL",
        "credential": "PA",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2012-10-19",
        "last_updated": "2020-07-23",
        "certification_date": "2020-07-23",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "MS",
            "license": "00172",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CIGNA",
            "identifier": "5874982",
            "state": "MS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "05153323",
            "state": "MS"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AETNA",
            "identifier": "9469937",
            "state": "MS"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UNITED HEALTHCARE",
            "identifier": "3528936",
            "state": "MS"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "dwagner20669@directpatientrecord.com",
            "affiliation": "N",
            "use": "HIE",
            "useDescription": "Health Information Exchange (HIE)",
            "address_1": "2313 Highway 15 N",
            "city": "Laurel",
            "state": "MS",
            "country_code": "US",
            "postal_code": "394401805",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Universal Connectivity Specialists, LLC
• Unlimited Dreams II
• Laura Valentine, RN
• Daniel Frederick Vial, M.D.
• William Vinzant, CMHT
• Wal-Mart Stores East LP (Walmart Pharmacy 10-0501)
• Wal-Mart Stores, Inc. (Vision Center 30-0501)
• Walgreen Co (Walgreens #09037)
• Latoya Renee Walker, M.D.
• Jon T Wall, CRNA

• Medical Physician Assistant in Laurel, MS
• Providers in Laurel, MS by specialty
• Medical Physician Assistant in Mississippi

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 23, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.