Provider Demographics
NPI:1205092400
Name:REGAN WAGNER, COURTNEY (MD)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:REGAN WAGNER
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 HIGHLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-6902
Mailing Address - Country:US
Mailing Address - Phone:406-414-5070
Mailing Address - Fax:
Practice Address - Street 1:931 HIGHLAND BLVD STE 3130
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-6914
Practice Address - Country:US
Practice Address - Phone:406-414-5070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-06
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT89785207RH0003X
IL036127673207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1205092400Medicaid