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General NPI Number Information
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NPI Number | 1104382936
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Entity Type | Individual
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Provider Name | ASHLEY CHRISTINE WAGNER
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Gender | Female
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Dates
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Enumeration Date | 02/18/2019
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Last Update Date | 02/18/2019
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Provider Practice Location Address
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Address Line | 3724 EXECUTIVE CENTER DR STE G10
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City | AUSTIN
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State | TX
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Zip | 78731-1665
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Country | US
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Telephone | 512-324-9720
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Fax |
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Provider Business Mailing Address
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Address Line | 428 LEWISVILLE LN
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City | LEANDER
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State | TX
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Zip | 78641-4046
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Country | US
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Telephone | 361-500-2803
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Fax |
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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 | 2083S0010X
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Taxonomy Name | Sports Medicine (Preventive Medicine) Physician
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License Number | AT5055
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License Number State | TX
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