Provider Demographics
NPI:1730462755
Name:WAGNER, MARY E
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:E
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2549 ODANIEL RD
Mailing Address - Street 2:
Mailing Address - City:SEGUIN
Mailing Address - State:TX
Mailing Address - Zip Code:78155-1240
Mailing Address - Country:US
Mailing Address - Phone:830-303-2508
Mailing Address - Fax:830-379-5411
Practice Address - Street 1:2549 ODANIEL RD
Practice Address - Street 2:
Practice Address - City:SEGUIN
Practice Address - State:TX
Practice Address - Zip Code:78155-1240
Practice Address - Country:US
Practice Address - Phone:830-303-2508
Practice Address - Fax:830-379-5411
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies