Provider Demographics
NPI:1043217797
Name:WAGNER, MICHAEL D (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 SPRUCE ST STE B
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-3455
Mailing Address - Country:US
Mailing Address - Phone:505-753-7499
Mailing Address - Fax:505-753-7578
Practice Address - Street 1:1010 SPRUCE ST 3RD FL AREA 5
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2724
Practice Address - Country:US
Practice Address - Phone:505-367-0340
Practice Address - Fax:505-747-2025
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM81335207Q00000X
NM81-335207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM33308Medicaid
E001106004Medicare PIN
NM33308Medicaid