Provider Demographics
NPI:1700804309
Name:WAGNER, KENNETH W (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:W
Last Name:WAGNER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17070 RED OAK DR
Mailing Address - Street 2:STE 507
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77090-2617
Mailing Address - Country:US
Mailing Address - Phone:281-719-9681
Mailing Address - Fax:281-791-0059
Practice Address - Street 1:17115 RED OAK DR
Practice Address - Street 2:SUITE 211
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090-2641
Practice Address - Country:US
Practice Address - Phone:281-719-9681
Practice Address - Fax:281-791-0059
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00865363AS0400X, 363A00000X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8Y8598OtherBCBSTX
TX198928701Medicaid
TX87N250OtherBCBS
TX8Y8598OtherBCBSTX
TX82N629Medicare PIN
TX970015919Medicare PIN
TX8L4957Medicare PIN