Basic Information
| Provider Information | |||||||||
| NPI: | 1487743969 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | DONNA | ||||||||
| MiddleName: | RM | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1501 E MOCKINGBIRD LN | ||||||||
| Address2: | STE 101 | ||||||||
| City: | VICTORIA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 779042178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3615736291 | ||||||||
| FaxNumber: | 3615762434 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 E MOCKINGBIRD LN | ||||||||
| Address2: | #101 | ||||||||
| City: | VICTORIA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 779042155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3615136291 | ||||||||
| FaxNumber: | 3615762434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 09/07/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | J0338 | TX | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 742710179A011 | 01 | TX | CHAMPUS | OTHER | MDJ0338TX | 01 | TX | WORKERS COMPENSATION | OTHER | 123558203 | 05 | TN | MEDICAID |