Provider Demographics
NPI:1194021931
Name:WAGNER, SHERON A (DNP, NNP-BC)
Entity Type:Individual
Prefix:
First Name:SHERON
Middle Name:A
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DNP, NNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 660599
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0599
Mailing Address - Country:US
Mailing Address - Phone:214-590-8487
Mailing Address - Fax:
Practice Address - Street 1:1500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4917
Practice Address - Country:US
Practice Address - Phone:817-702-1166
Practice Address - Fax:817-702-1405
Is Sole Proprietor?:No
Enumeration Date:2011-01-26
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP119908363LN0000X
TX795013363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal