Provider Demographics
NPI:1811914336
Name:WAGNER, CHRISTINE W (NP)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:W
Last Name:WAGNER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1935 MEDICAL DISTRICT DR
Mailing Address - Street 2:PAVILION F 5114
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-7701
Mailing Address - Country:US
Mailing Address - Phone:214-456-4597
Mailing Address - Fax:214-456-8317
Practice Address - Street 1:1935 MEDICAL DISTRICT DR
Practice Address - Street 2:PAVILION F 5114
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7701
Practice Address - Country:US
Practice Address - Phone:214-456-4597
Practice Address - Fax:214-456-8317
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX449805363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner