Provider Demographics
NPI:1013929744
Name:WAGNER, YVONNE M (RN, ANP)
Entity Type:Individual
Prefix:
First Name:YVONNE
Middle Name:M
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RN, ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 HIGHWAY 71 S
Mailing Address - Street 2:101
Mailing Address - City:COLUMBUS
Mailing Address - State:TX
Mailing Address - Zip Code:78934-3011
Mailing Address - Country:US
Mailing Address - Phone:979-732-2318
Mailing Address - Fax:979-732-2310
Practice Address - Street 1:2122 HIGHWAY 71 S
Practice Address - Street 2:101
Practice Address - City:COLUMBUS
Practice Address - State:TX
Practice Address - Zip Code:78934-3011
Practice Address - Country:US
Practice Address - Phone:979-732-2318
Practice Address - Fax:979-732-2310
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX231032363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112272302Medicaid
TX112272305Medicaid
TX112272305Medicaid