Provider Demographics
NPI:1518920313
Name:WAGNER, NATHAN S (PSYD)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:S
Last Name:WAGNER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1544 OXBOW DR STE 212
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-5189
Mailing Address - Country:US
Mailing Address - Phone:970-765-2060
Mailing Address - Fax:970-808-2600
Practice Address - Street 1:1544 OXBOW DR STE 212
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-5189
Practice Address - Country:US
Practice Address - Phone:970-765-2060
Practice Address - Fax:970-808-2600
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS--008851-L103T00000X
IL071.007585103TC0700X
COPSY000.4998103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01965831Medicaid
IL7599513OtherAETNA
IL477318OtherVALUE OPTIONS
IL588446000OtherMAGELLAN
PA01965831Medicaid