Provider Demographics
NPI:1952685125
Name:WAGNER, DERRICK C (FNP-C)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:C
Last Name:WAGNER
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16107 KENSINGTON DR
Mailing Address - Street 2:SUITE 126
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77089-6041
Mailing Address - Country:US
Mailing Address - Phone:361-676-5519
Mailing Address - Fax:713-439-7995
Practice Address - Street 1:3002 SAM HOUSTON DR
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-2682
Practice Address - Country:US
Practice Address - Phone:361-578-5730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-05
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP120984363L00000X, 363LF0000X
TX737124363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner