MEDICARE: MICHAEL D 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	81335	NM
2	207RP1001X	Pulmonary Disease Physician	81-335	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043217797
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL D WAGNER MD

Provider Business Mailing Address
First Line	:	835 SPRUCE ST STE B
Second Line	:
City	:	ESPANOLA
State	:	NM
Zip	:	87532-3455
Country	:	US
Telephone Number	:	505-753-7499
Fax Number	:	505-753-7578

Provider Business Practice Location Address
First Line	:	1010 SPRUCE ST 3RD FL AREA 5
Second Line	:
City	:	ESPANOLA
State	:	NM
Zip	:	87532-2724
Country	:	US
Telephone Number	:	505-367-0340
Fax Number	:	505-747-2025

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

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	04/11/2024

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Directions to “ MICHAEL D WAGNER MD” Practice Location

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