Provider Demographics
NPI:1669429825
Name:WAGSTAFF, NATHAN VINCENT (MD)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:VINCENT
Last Name:WAGSTAFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:43800 GARFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1136
Mailing Address - Country:US
Mailing Address - Phone:800-848-0202
Mailing Address - Fax:586-226-6949
Practice Address - Street 1:22151 MOROSS RD
Practice Address - Street 2:313
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2167
Practice Address - Country:US
Practice Address - Phone:313-343-3494
Practice Address - Fax:313-343-4932
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5315026029OtherCONTROLLED SUBSTANCE
MI5315026029OtherCONTROLLED SUBSTANCE