Provider Demographics
NPI:1396454484
Name:WAGONER HEALTH CLINIC, PLLC
Entity type:Organization
Organization Name:WAGONER HEALTH CLINIC, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBEKAH
Authorized Official - Middle Name:M
Authorized Official - Last Name:WAGONER
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, FNP-C
Authorized Official - Phone:936-715-5353
Mailing Address - Street 1:1023 N MOUND ST STE E
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961-4453
Mailing Address - Country:US
Mailing Address - Phone:936-305-4130
Mailing Address - Fax:936-305-4127
Practice Address - Street 1:1023 N MOUND ST STE E
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-4453
Practice Address - Country:US
Practice Address - Phone:936-305-4130
Practice Address - Fax:936-305-4127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-17
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty