Provider Demographics
NPI:1750539144
Name:WAGNER, STUART M JR
Entity type:Individual
Prefix:MR
First Name:STUART
Middle Name:M
Last Name:WAGNER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4407 BEE CAVES RD.
Mailing Address - Street 2:BLD.1, SUITE 112
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746
Mailing Address - Country:US
Mailing Address - Phone:512-328-4999
Mailing Address - Fax:512-328-4979
Practice Address - Street 1:4407 BEE CAVES RD.
Practice Address - Street 2:BLD.1, SUITE 112
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746
Practice Address - Country:US
Practice Address - Phone:512-328-4999
Practice Address - Fax:512-328-4979
Is Sole Proprietor?:No
Enumeration Date:2008-08-28
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX50428231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX309341102Medicaid
TX309341101Medicaid
TXTXB166080Medicare PIN
TXTXB166079Medicare PIN