MITCHEL ALAN WAGNER DO Medical Doctor License verification

Business Entity

CANCELLED

License Type

Medical Doctor

Description

TEMPORARY MEDICAL PERMIT

License Number

125078478

License Status

CANCELLED

Business

Title

First Name

MITCHEL

Middle

ALAN

Last Name

WAGNER

Business Name

MITCHEL ALAN WAGNER DO

Original Issue Date

07/01/2021

Effective Date

07/01/2021

Expiration Date

06/30/2024

City

PEORIA

State

Zip

61605

County

PEORIA

Specialty/Qualifier

Emergency Medicine

Ever Disciplined

LastModifiedDate

04/07/2021