Basic Information
| Provider Information | |||||||||
| NPI: | 1689735615 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 162835 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761612835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173340530 | ||||||||
| FaxNumber: | 8173340235 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828854054 | ||||||||
| FaxNumber: | 6828857497 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 05/18/2010 | ||||||||
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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 | 367500000X | 704521 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 137345809 | 01 | TX | MEDICAID GROUP TPI | OTHER | 140442853 | 01 | TX | CSHCN GROUP TPI | OTHER | 10013790 | 01 | TX | AMERIGROUP PIN | OTHER | 1447220850 | 01 | GRP NPI NUMBER | OTHER | 164929503 | 05 | TX | MEDICAID | 2460115 | 01 | TX | UHC PIN | OTHER | 164929504 | 01 | TX | CSHCN | OTHER | 00N47F | 01 | TX | MEDICARE GROUP PIN | OTHER |