Provider Demographics
NPI:1427092980
Name:WAGNER, HALEY ELYSE (DO)
Entity type:Individual
Prefix:
First Name:HALEY
Middle Name:ELYSE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 N HIGHWAY 77
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-1128
Mailing Address - Country:US
Mailing Address - Phone:972-923-1686
Mailing Address - Fax:972-923-9268
Practice Address - Street 1:505 N HIGHWAY 77
Practice Address - Street 2:SUITE 200
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-1128
Practice Address - Country:US
Practice Address - Phone:972-923-1686
Practice Address - Fax:972-923-9268
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM2185208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1773210-02Medicaid
TX8BR069OtherBCBS
TX177321003Medicaid
TX8F5194OtherBCBS
TX1773210-02Medicaid
TX8F5194OtherBCBS
TX8F3673Medicare PIN