Provider Demographics
NPI:1104382936
Name:WAGNER, ASHLEY CHRISTINE
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:CHRISTINE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 LEWISVILLE LN
Mailing Address - Street 2:
Mailing Address - City:LEANDER
Mailing Address - State:TX
Mailing Address - Zip Code:78641-4046
Mailing Address - Country:US
Mailing Address - Phone:361-500-2803
Mailing Address - Fax:
Practice Address - Street 1:3724 EXECUTIVE CENTER DR STE G10
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-1665
Practice Address - Country:US
Practice Address - Phone:512-324-9720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-18
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT50552083S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAT5055OtherSTATE OF TEXAS LICENSURE
2000007383OtherBOARD OF CERTIFICATION