Provider Demographics
NPI:1720019177
Name:WAGNER, BRENT (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:
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 1:11820 WILSHIRE AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-1578
Mailing Address - Country:US
Mailing Address - Phone:210-268-7985
Mailing Address - Fax:
Practice Address - Street 1:7703 FLOYD CURL DR # MC7882
Practice Address - Street 2:NEPHROLOGY/MEDICINE/UTHSCSA
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3901
Practice Address - Country:US
Practice Address - Phone:210-567-4700
Practice Address - Fax:210-567-4731
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2044207R00000X, 207RN0300X
NMMD2018-0891207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX174006001Medicaid
TX8D6551Medicare ID - Type Unspecified