Provider Demographics
NPI:1598164766
Name:WAGENMAN, BRIANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:BRIANNE
Middle Name:
Last Name:WAGENMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 MURCHISON DR STE 215
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-2918
Mailing Address - Country:US
Mailing Address - Phone:951-544-3254
Mailing Address - Fax:
Practice Address - Street 1:1700 MURCHISON DR STE 215
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-2918
Practice Address - Country:US
Practice Address - Phone:951-544-3254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-13
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA15098363AM0700X
CAPA51753363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical