MEDICARE: CHRISTINA MARIE WAGNER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1083505713
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINA MARIE WAGNER

Provider Business Mailing Address
First Line	:	1912 BLUEBONNET DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76111-1603
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1912 BLUEBONNET DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76111-1603
Country	:	US
Telephone Number	:	817-807-3876
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2025
Last Update Date	:	07/11/2025

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