Healthcare Provider Details

I. General information

NPI: 1013964162
Provider Name (Legal Business Name): WAGONER MEDICAL GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 02/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N ALPHA ST
GRAND ISLAND NE
68803-4320
US

IV. Provider business mailing address

800 N ALPHA ST
GRAND ISLAND NE
68803-4320
US

V. Phone/Fax

Practice location:
  • Phone: 308-382-2010
  • Fax: 308-382-9549
Mailing address:
  • Phone: 308-382-2010
  • Fax: 308-382-9549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number StateNE

VIII. Authorized Official

Name: MRS. JODY M HUGHES
Title or Position: OFFICE MANAGER
Credential: RN
Phone: 308-382-2010