Provider Demographics
NPI:1881865640
Name:VANWAGNER, LISA B (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:B
Last Name:VANWAGNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:LISA
Other - Middle Name:BETH
Other - Last Name:SANDSTROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-7208
Mailing Address - Country:US
Mailing Address - Phone:214-645-6284
Mailing Address - Fax:
Practice Address - Street 1:6201 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-3111
Practice Address - Country:US
Practice Address - Phone:214-633-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-19
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036124551207RT0003X, 207RG0100X, 207RI0008X
TXT5230207RI0008X, 207RT0003X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207RT0003XAllopathic & Osteopathic PhysiciansInternal MedicineTransplant Hepatology
No207RI0008XAllopathic & Osteopathic PhysiciansInternal MedicineHepatology