Provider Demographics
NPI:1003890112
Name:WAGNER, LANA K (MD)
Entity Type:Individual
Prefix:
First Name:LANA
Middle Name:K
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:4100 HIGH RESORT BLVD SE
Practice Address - Street 2:PMG RIO RANCHO HIGH RESORT 4100
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-5901
Practice Address - Country:US
Practice Address - Phone:505-462-8520
Practice Address - Fax:505-462-8510
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2015-10-29
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Provider Licenses
StateLicense IDTaxonomies
NM2000303207Q00000X
NM2000-303207QS1201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS1201XAllopathic & Osteopathic PhysiciansFamily MedicineSleep Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H46241Medicare UPIN