Provider Demographics
NPI:1689735615
Name:WAGNER, DAVID M (CRNA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
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:PO BOX 162835
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161-2835
Mailing Address - Country:US
Mailing Address - Phone:817-334-0530
Mailing Address - Fax:817-334-0235
Practice Address - Street 1:801 7TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2733
Practice Address - Country:US
Practice Address - Phone:682-885-4054
Practice Address - Fax:682-885-7497
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX704521367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX137345809OtherMEDICAID GROUP TPI
TX140442853OtherCSHCN GROUP TPI
TX10013790OtherAMERIGROUP PIN
1447220850OtherGRP NPI NUMBER
TX164929503Medicaid
TX2460115OtherUHC PIN
TX164929504OtherCSHCN
TX00N47FOtherMEDICARE GROUP PIN
TX8L9053Medicare PIN
TX00N47FOtherMEDICARE GROUP PIN