Healthcare Provider Details

I. General information

NPI: 1043217797
Provider Name (Legal Business Name): MICHAEL D WAGNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 04/11/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 SPRUCE ST 3RD FL AREA 5
ESPANOLA NM
87532-2724
US

IV. Provider business mailing address

835 SPRUCE ST STE B
ESPANOLA NM
87532-3455
US

V. Phone/Fax

Practice location:
  • Phone: 505-367-0340
  • Fax: 505-747-2025
Mailing address:
  • Phone: 505-753-7499
  • Fax: 505-753-7578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number81335
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number81-335
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: