Basic Information
| Provider Information | |||||||||
| NPI: | 1144422098 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 TRINITY ST STOP Z0200 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787121850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124955512 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3501 MILLS AVE | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123242080 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2007 | ||||||||
| LastUpdateDate: | 01/10/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | N2876 | TX | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.