Provider Demographics
NPI:1407673593
Name:WAGONER, KEITH WILLIAM (BSN, RN-BC)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:WILLIAM
Last Name:WAGONER
Suffix:
Gender:M
Credentials:BSN, RN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 ARAPAHO TRL
Mailing Address - Street 2:
Mailing Address - City:MABANK
Mailing Address - State:TX
Mailing Address - Zip Code:75156-9176
Mailing Address - Country:US
Mailing Address - Phone:903-603-3979
Mailing Address - Fax:
Practice Address - Street 1:110 N STATE HIGHWAY 274
Practice Address - Street 2:
Practice Address - City:KEMP
Practice Address - State:TX
Practice Address - Zip Code:75143-4617
Practice Address - Country:US
Practice Address - Phone:430-255-2199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-20
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX919371163WG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0600XNursing Service ProvidersRegistered NurseGerontology