Provider Demographics
NPI:1033103569
Name:WAGNER, ANNE P (MD)
Entity Type:Individual
Prefix:DR
First Name:ANNE
Middle Name:P
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ROSALYN
Other - Middle Name:P
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:605 E SAN ANTONIO ST
Mailing Address - Street 2:SUITE 430E
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-6050
Mailing Address - Country:US
Mailing Address - Phone:361-576-0011
Mailing Address - Fax:361-576-4084
Practice Address - Street 1:605 E SAN ANTONIO ST
Practice Address - Street 2:SUITE 430E
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-6050
Practice Address - Country:US
Practice Address - Phone:361-576-0011
Practice Address - Fax:361-576-4084
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG6095207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX033323902Medicaid
TX033323902Medicaid
TXC23036Medicare UPIN
760524482OtherFEDERAL TAX ID NUMBER
TXP00091361Medicare PIN