Healthcare Provider Details

I. General information

NPI: 1588577498
Provider Name (Legal Business Name): TYLER WAGNER PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 PAGE DR S STE 102B
FARGO ND
58103-3562
US

IV. Provider business mailing address

1330 PAGE DR S STE 102B
FARGO ND
58103-3562
US

V. Phone/Fax

Practice location:
  • Phone: 701-414-4596
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number206041
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: