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General NPI Number Information
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NPI Number | 1043217797
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Entity Type | Individual
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Provider Name | MICHAEL D WAGNER MD
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Gender | Male
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Dates
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Enumeration Date | 07/07/2005
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Last Update Date | 04/11/2024
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Provider Practice Location Address
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Address Line | 1010 SPRUCE ST 3RD FL AREA 5
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City | ESPANOLA
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State | NM
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Zip | 87532-2724
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Country | US
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Telephone | 505-367-0340
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Fax | 505-747-2025
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Provider Business Mailing Address
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Address Line | 835 SPRUCE ST STE B
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City | ESPANOLA
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State | NM
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Zip | 87532-3455
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Country | US
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Telephone | 505-753-7499
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Fax | 505-753-7578
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 81335
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 207RP1001X
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Taxonomy Name | Pulmonary Disease Physician
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License Number | 81-335
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License Number State | NM
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