1790732204 NPI number — TROY D WAGNER

Table of content: TROY D WAGNER (NPI 1790732204)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790732204 NPI number — TROY D WAGNER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAGNER
Provider First Name:
TROY
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1790732204
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 35100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BILLINGS
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59107-5100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-238-2500
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2900 12TH AVE N
Provider Second Line Business Practice Location Address:
SUITE 140W
Provider Business Practice Location Address City Name:
BILLINGS
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59101-7506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-238-6540
Provider Business Practice Location Address Fax Number:
406-238-6599
Provider Enumeration Date:
05/28/2006

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: 363A00000X , with the licence number:  442 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X , with the licence number: MED-PAC-LIC-442 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4307970 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000900323 . This is a "BCBS PIN" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".




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