1619192192 NPI number — WILLIAM W WAGNON MD PA

Table of content: (NPI 1619192192)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619192192 NPI number — WILLIAM W WAGNON MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLIAM W WAGNON MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619192192
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2801 S JOHN REDDITT DR
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
LUFKIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75904-5666
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-632-6111
Provider Business Mailing Address Fax Number:
936-632-9182

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2801 S JOHN REDDITT DR
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
LUFKIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75904-5666
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-632-6111
Provider Business Practice Location Address Fax Number:
936-632-9182
Provider Enumeration Date:
04/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WAGNON
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
W
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
936-632-6111

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  8596-TG , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: F2087 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 093898701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1902895345 . This is a "NPI TYPE I" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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