Provider Demographics
NPI:1649216896
Name:WAGNER, LENARD D (MD)
Entity Type:Individual
Prefix:
First Name:LENARD
Middle Name:D
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W LEA ST
Mailing Address - Street 2:
Mailing Address - City:HOBBS
Mailing Address - State:NM
Mailing Address - Zip Code:88240-5110
Mailing Address - Country:US
Mailing Address - Phone:575-391-0270
Mailing Address - Fax:575-391-0271
Practice Address - Street 1:1600 NORTH MAIN
Practice Address - Street 2:
Practice Address - City:LOVINGTON
Practice Address - State:NM
Practice Address - Zip Code:88260-2813
Practice Address - Country:US
Practice Address - Phone:575-396-6611
Practice Address - Fax:575-396-0318
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM86-141207QG0300X
NMCS00009180208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM36954Medicaid
NM348334601Medicare PIN
NM36954Medicaid