Provider Demographics
NPI:1790732204
Name:WAGNER, TROY D
Entity Type:Individual
Prefix:
First Name:TROY
Middle Name:D
Last Name:WAGNER
Suffix:
Gender:M
Credentials:
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 35100
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59107-5100
Mailing Address - Country:US
Mailing Address - Phone:406-238-2500
Mailing Address - Fax:
Practice Address - Street 1:2900 12TH AVE N
Practice Address - Street 2:SUITE 140W
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-7506
Practice Address - Country:US
Practice Address - Phone:406-238-6540
Practice Address - Fax:406-238-6599
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT442363A00000X
MTMED-PAC-LIC-442363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT4307970Medicaid
MT000900323OtherBCBS PIN
MT1153260007Medicare PIN
MTQ32362Medicare UPIN
MT4307970Medicaid
MT011000860Medicare PIN