Provider Demographics
NPI:1356504674
Name:WAGNER, JENNIFER KATHLEEN (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:KATHLEEN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2968 RODEO PARK DR W STE 150
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-6383
Mailing Address - Country:US
Mailing Address - Phone:505-913-5227
Mailing Address - Fax:
Practice Address - Street 1:2968 RODEO PARK DR W STE 150
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-6383
Practice Address - Country:US
Practice Address - Phone:505-913-5227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-07
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10030789207X00000X
TXR2248207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM59076356Medicaid