Provider Demographics
NPI:1356322127
Name:WAGNER MEDICAL CLINIC L.L.P.
Entity Type:Organization
Organization Name:WAGNER MEDICAL CLINIC L.L.P.
Other - Org Name:MOULTON CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-594-3824
Mailing Address - Street 1:PO BOX 965
Mailing Address - Street 2:
Mailing Address - City:SHINER
Mailing Address - State:TX
Mailing Address - Zip Code:77984-0965
Mailing Address - Country:US
Mailing Address - Phone:361-594-3824
Mailing Address - Fax:
Practice Address - Street 1:100 S PECAN
Practice Address - Street 2:
Practice Address - City:MOULTON
Practice Address - State:TX
Practice Address - Zip Code:77975-0238
Practice Address - Country:US
Practice Address - Phone:361-594-3824
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QR1300X
PA11615363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX063662301Medicaid
TX458968Medicare Oscar/Certification