Provider Demographics
NPI:1043511967
Name:WAGNER, LINDA O (FNP-C)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:O
Last Name:WAGNER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60183
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78466-0183
Mailing Address - Country:US
Mailing Address - Phone:361-885-7722
Mailing Address - Fax:361-885-7792
Practice Address - Street 1:613 ELIZABETH
Practice Address - Street 2:STE 813
Practice Address - City:CORPUS CHRRISTI
Practice Address - State:TX
Practice Address - Zip Code:78404-2232
Practice Address - Country:US
Practice Address - Phone:361-885-7722
Practice Address - Fax:361-885-7792
Is Sole Proprietor?:No
Enumeration Date:2010-11-09
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX669710363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX669710OtherSTATE LICENSE
TXTXB122674OtherMEDICARE PTAN RN