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General NPI Number Information
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NPI Number | 1952685125
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Entity Type | Individual
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Provider Name | DERRICK C WAGNER FNP-C
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Gender | Male
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Dates
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Enumeration Date | 10/05/2011
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Last Update Date | 09/25/2024
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Provider Practice Location Address
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Address Line | 3002 SAM HOUSTON DR
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City | VICTORIA
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State | TX
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Zip | 77904-2682
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Country | US
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Telephone | 361-578-5730
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Fax |
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Provider Business Mailing Address
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Address Line | 16107 KENSINGTON DR SUITE 126
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City | HOUSTON
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State | TX
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Zip | 77089-6041
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Country | US
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Telephone | 361-676-5519
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Fax | 713-439-7995
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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 | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | AP120984
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 737124
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License Number State | TX
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Taxonomy #3
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | AP120984
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License Number State | TX
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