MEDICARE: CHRISTINE W WAGNER NP

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	363L00000X	Nurse Practitioner	449805	TX

General Provider Information

NPI Number	:	1811914336
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINE W WAGNER NP

Provider Business Mailing Address
First Line	:	1935 MEDICAL DISTRICT DR
Second Line	:	PAVILION F 5114
City	:	DALLAS
State	:	TX
Zip	:	75235-7701
Country	:	US
Telephone Number	:	214-456-4597
Fax Number	:	214-456-8317

Provider Business Practice Location Address
First Line	:	1935 MEDICAL DISTRICT DR
Second Line	:	PAVILION F 5114
City	:	DALLAS
State	:	TX
Zip	:	75235-7701
Country	:	US
Telephone Number	:	214-456-4597
Fax Number	:	214-456-8317

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

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	08/04/2008

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