Provider Demographics
NPI:1841499258
Name:WAGNER, SCOTT JOHN (CNOR RNFA)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:JOHN
Last Name:WAGNER
Suffix:
Gender:M
Credentials:CNOR RNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3322 COLORADO BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76210-6889
Mailing Address - Country:US
Mailing Address - Phone:940-387-7588
Mailing Address - Fax:940-566-0881
Practice Address - Street 1:3322 COLORADO BLVD STE 101
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76210-6889
Practice Address - Country:US
Practice Address - Phone:940-387-7588
Practice Address - Fax:940-566-0881
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX695886163WR0006X
TX1018610363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX695886OtherRN