Basic Information
| Provider Information | |||||||||
| NPI: | 1871528455 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | FREDERICK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26666 | ||||||||
| Address2: | PHS PROVIDER ENROLLMENT | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871256666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059236770 | ||||||||
| FaxNumber: | 8555404722 | ||||||||
| Practice Location | |||||||||
| Address1: | 8300 CONSTITUTION AVE NE SUITE 1106 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871107624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052912770 | ||||||||
| FaxNumber: | 5052912707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 05/31/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 51715 | CA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 40658 | CO | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | G0247 | TX | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 2003-00422 | NC | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207LP2900X | MD36735 | SC | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207LP2900X | 2002-0462 | NM | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 94173028 | 05 | NM | MEDICAID |