Provider Demographics
NPI:1093761041
Name:WAGNER DIX, NICOLE LYNN (DO)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:WAGNER DIX
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 S 169TH ST FL 3
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68118-9300
Mailing Address - Country:US
Mailing Address - Phone:402-354-4822
Mailing Address - Fax:402-941-7017
Practice Address - Street 1:700 E 29TH ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-2384
Practice Address - Country:US
Practice Address - Phone:402-721-3133
Practice Address - Fax:402-941-7017
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE466207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE466OtherMEDICAL LICENSE
NE466OtherMEDICAL LICENSE