Provider Demographics
NPI:1902429749
Name:WAGONER, MICHAEL WAYNE (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WAYNE
Last Name:WAGONER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 AZURE LN
Mailing Address - Street 2:
Mailing Address - City:CELINA
Mailing Address - State:TX
Mailing Address - Zip Code:75009-1798
Mailing Address - Country:US
Mailing Address - Phone:757-971-0190
Mailing Address - Fax:
Practice Address - Street 1:1109 AZURE LN
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:TX
Practice Address - Zip Code:75009-1798
Practice Address - Country:US
Practice Address - Phone:757-971-0190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-27
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT5488207Q00000X
UTBP10071692390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine