Basic Information
| Provider Information | |||||||||
| NPI: | 1770035545 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4800 ALBERTA AVE | ||||||||
| Address2: | 101 | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799052709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9152154478 | ||||||||
| FaxNumber: | 9155455755 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 TRANSMOUNTAIN ROAD | ||||||||
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| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 79911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9152158408 | ||||||||
| FaxNumber: | 9156129251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2016 | ||||||||
| LastUpdateDate: | 10/27/2016 | ||||||||
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| AuthorizedOfficialLastName: | WAGNER | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | MARC | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9152154475 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0101X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology |
No ID Information.