Provider Demographics
NPI:1033129150
Name:WAGNER, ERIK W (FNP)
Entity Type:Individual
Prefix:
First Name:ERIK
Middle Name:W
Last Name:WAGNER
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4824 E BASELINE RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4676
Mailing Address - Country:US
Mailing Address - Phone:480-969-4040
Mailing Address - Fax:480-830-1042
Practice Address - Street 1:4838 E. BASELINE RD.
Practice Address - Street 2:BLDG 2, SUITE 109
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4677
Practice Address - Country:US
Practice Address - Phone:480-969-4040
Practice Address - Fax:480-830-1042
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTAP4826363LF0000X
AZAP4826363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ233314OtherMEDICARE PTAN
AZ825839Medicaid