Provider Demographics
NPI:1114648417
Name:WAGNER, AIMEE JULY (NP)
Entity Type:Individual
Prefix:
First Name:AIMEE
Middle Name:JULY
Last Name:WAGNER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:AIMEE
Other - Middle Name:JULY
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:310 FELDSPAR WAY
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59106-2357
Mailing Address - Country:US
Mailing Address - Phone:406-850-2567
Mailing Address - Fax:
Practice Address - Street 1:2800 10TH AVE N
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-0703
Practice Address - Country:US
Practice Address - Phone:406-657-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTNUR-APRN-LIC-197072363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTNUR-APRN-LIC-197072Medicaid