Basic Information
| Provider Information | |||||||||
| NPI: | 1053785840 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 GRANT BLVD W | ||||||||
| Address2: | |||||||||
| City: | WABASHA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559811042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6515655600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1200 GRANT BLVD W | ||||||||
| Address2: | |||||||||
| City: | WABASHA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55981 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6515655600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2015 | ||||||||
| LastUpdateDate: | 11/14/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | CNP 4307 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163W00000X | R 170201-9 | MN | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | CNP 4307 | 01 | MN | APRN LICENSE | OTHER | R 170201-9 | 01 | MN | RN LICENSE | OTHER |