Healthcare Provider Details

I. General information

NPI: 1215899786
Provider Name (Legal Business Name): AMANSA RAE WAGNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2025
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 BEES CAVE ROAD STE C106
WESTLAKE HILLS TX
78746-6493
US

IV. Provider business mailing address

4201 BEE CAVES RD STE C106
WEST LAKE HILLS TX
78746-6493
US

V. Phone/Fax

Practice location:
  • Phone: 210-834-9087
  • Fax:
Mailing address:
  • Phone: 210-834-9087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1195987
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: