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Individual
TIMOTHY J WAGNER
Active
Individual
TIMOTHY J WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
J0340
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
135624802
—
TX
01
—
82Y592
BC
TX
01
—
836T776
BLUE CROSS
TX
Enumeration date
11/09/2005
Last updated
07/18/2008
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