| NPI | 1902124225 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | BRIAN K WAGNER Owner 860-653-4708 |
| Organization Subpart ? | No |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: CT CT000793) |
| Additional Taxonomies | 213ES0131X Podiatrist Foot Surgery (Licence: CT CT000793) |
| Enumeration Date | 2010-05-11 |
| Last Update Date | 2010-06-04 |