Healthcare Provider Details

I. General information

NPI: 1346754249
Provider Name (Legal Business Name): LISA MARIE WAGNER APN NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2017
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

249 KODIAK DR UNIT 201
BASALT CO
81621-8140
US

IV. Provider business mailing address

249 KODIAK DR UNIT 201
BASALT CO
81621-8140
US

V. Phone/Fax

Practice location:
  • Phone: 970-618-8796
  • Fax: 970-645-3168
Mailing address:
  • Phone: 970-618-8796
  • Fax: 970-645-3168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN.0993561-NP
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: