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General NPI Number Information
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NPI Number | 1801142302
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Entity Type | Individual
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Provider Name | CAROLYN WAGNER
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Gender | Female
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Dates
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Enumeration Date | 08/02/2012
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Last Update Date | 07/22/2025
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Provider Practice Location Address
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Address Line | 208 OAK DR S STE 400
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City | LAKE JACKSON
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State | TX
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Zip | 77566-5640
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Country | US
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Telephone | 979-285-2900
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Fax |
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Provider Business Mailing Address
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Address Line | 6431 FANNIN ST MSB 3.020B
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City | HOUSTON
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State | TX
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Zip | 77030-1501
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Country | US
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Telephone |
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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 | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | Q3306
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License Number State | TX
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