Provider Demographics
NPI:1679562516
Name:WAGNER, SCOTT BRIAN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:BRIAN
Last Name:WAGNER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6043 ENNIS JOSLIN RD
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78412-2805
Mailing Address - Country:US
Mailing Address - Phone:361-992-3361
Mailing Address - Fax:361-992-0487
Practice Address - Street 1:613 ELIZABETH ST
Practice Address - Street 2:SUITE 605
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78404-2220
Practice Address - Country:US
Practice Address - Phone:361-883-6211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX655472367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0034548-02Medicaid
TX0034548-02Medicaid