Basic Information
| Provider Information | |||||||||
| NPI: | 1255789616 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER EL PASO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4800 ALBERTA AVE. | ||||||||
| Address2: | STE 101 | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 79905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9152154478 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2000 B TRANSMOUNTAIN ROAD | ||||||||
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| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 79911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9152155626 | ||||||||
| FaxNumber: | 9155456984 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2016 | ||||||||
| LastUpdateDate: | 05/26/2016 | ||||||||
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| AuthorizedOfficialLastName: | WAGNER | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | MARC | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9152154478 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D. M.P.A. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.