Provider Demographics
NPI:1205220373
Name:WAGER, SHELBY YOUNG (RD)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:YOUNG
Last Name:WAGER
Suffix:
Gender:F
Credentials:RD
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 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6400
Mailing Address - Fax:
Practice Address - Street 1:619 S FLEISHEL AVE
Practice Address - Street 2:STE 327
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2004
Practice Address - Country:US
Practice Address - Phone:903-510-1173
Practice Address - Fax:903-525-1312
Is Sole Proprietor?:No
Enumeration Date:2015-03-26
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT83604133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX348718302Medicaid
TX75-2616977-124OtherTRICARE
TXP01464110OtherRAIL ROAD MEDICARE
TX75-0818167-015OtherTRICARE
TX348718301Medicaid
TXP01464094OtherRAIL ROAD MEDICARE
TX8FA581OtherBCBS
TX8FA580OtherBCBS
TX348718301Medicaid
TXP01464110OtherRAIL ROAD MEDICARE