1043511967 NPI number — LINDA O WAGNER FNP-C

Table of content: LINDA O WAGNER FNP-C (NPI 1043511967)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043511967 NPI number — LINDA O WAGNER FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAGNER
Provider First Name:
LINDA
Provider Middle Name:
O
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043511967
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 60183
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORPUS CHRISTI
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78466-0183
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
361-885-7722
Provider Business Mailing Address Fax Number:
361-885-7792

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
613 ELIZABETH
Provider Second Line Business Practice Location Address:
STE 813
Provider Business Practice Location Address City Name:
CORPUS CHRRISTI
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78404-2232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
361-885-7722
Provider Business Practice Location Address Fax Number:
361-885-7792
Provider Enumeration Date:
11/09/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  669710 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 669710 . This is a "STATE LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: TXB122674 . This is a "MEDICARE PTAN RN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com