Provider Demographics
NPI:1871528455
Name:WAGNER, WILLIAM FREDERICK (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:FREDERICK
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
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 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:855-540-4722
Practice Address - Street 1:8300 CONSTITUTION AVE NE SUITE 1106
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-7624
Practice Address - Country:US
Practice Address - Phone:505-291-2770
Practice Address - Fax:505-291-2707
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51715207L00000X
CO40658207L00000X
TXG0247207L00000X
NC2003-00422207LP2900X
SCMD36735207LP2900X
NM2002-0462207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM94173028Medicaid