MEDICARE: LANA K WAGNER MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	2000303	NM
2	207QS1201X	Sleep Medicine (Family Medicine) Physician	2000-303	NM

General Provider Information

NPI Number	:	1003890112
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LANA K WAGNER MD

Provider Business Mailing Address
First Line	:	PO BOX 26666
Second Line	:	PHS PROVIDER ENROLLMENT
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87125-6666
Country	:	US
Telephone Number	:	505-923-6770
Fax Number	:	505-923-5354

Provider Business Practice Location Address
First Line	:	4100 HIGH RESORT BLVD SE
Second Line	:	PMG RIO RANCHO HIGH RESORT 4100
City	:	RIO RANCHO
State	:	NM
Zip	:	87124-5901
Country	:	US
Telephone Number	:	505-462-8520
Fax Number	:	505-462-8510

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2005
Last Update Date	:	10/29/2015

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