Provider Demographics
NPI:1679547046
Name:WAGNER, KATHRYN A (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:A
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 911230
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-1230
Mailing Address - Country:US
Mailing Address - Phone:972-997-8000
Mailing Address - Fax:972-234-2987
Practice Address - Street 1:414 NAVARRO ST
Practice Address - Street 2:STE 1407
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78205-2516
Practice Address - Country:US
Practice Address - Phone:210-277-6255
Practice Address - Fax:210-277-6256
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0875208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP01547654OtherRAILROAD MEDICARE
TX089953601Medicaid
TX089953605Medicaid
TX431608YKYCMedicare PIN
TXG02135Medicare UPIN