Healthcare Provider Details

I. General information

NPI: 1497915565
Provider Name (Legal Business Name): NICHOLAS J. WAGNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2008
Last Update Date: 02/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7900 FM 1826 BLDG. 1, STE. 220
AUSTIN TX
78737
US

IV. Provider business mailing address

7900 FM 1826 BLDG. 1, STE. 220
AUSTIN TX
78737
US

V. Phone/Fax

Practice location:
  • Phone: 512-288-9669
  • Fax: 512-498-0317
Mailing address:
  • Phone: 512-288-9669
  • Fax: 512-498-0317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberN9977
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: