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Individual
MR. KENNETH W WAGNER
Active
Individual
MR. KENNETH W WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA00865
TX
363AS0400X
Surgical Physician Assistant
PA00865
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
198928701
—
TX
01
—
87N250
BCBS
TX
01
—
8Y8598
BCBSTX
TX
Enumeration date
07/18/2006
Last updated
04/29/2021
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