Provider Demographics
NPI:1134662299
Name:WAGNER, REBECCA (PA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1581 AUSTIN HWY STE 102
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78218-1860
Mailing Address - Country:US
Mailing Address - Phone:210-436-8400
Mailing Address - Fax:833-452-1052
Practice Address - Street 1:1581 AUSTIN HWY STE 102
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78218-1860
Practice Address - Country:US
Practice Address - Phone:210-436-8400
Practice Address - Fax:833-452-1052
Is Sole Proprietor?:No
Enumeration Date:2016-11-22
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN