Individual
MATTHEW WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
1200 GRANT BLVD W, WABASHA, MN 55981
(651) 565-5600
Mailing address
1200 GRANT BLVD W, WABASHA, MN 55981-1042
(651) 565-5600
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
R 170201-9
MN
363LF0000X
Family Nurse Practitioner
Primary
CNP 4307
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
CNP 4307
APRN LICENSE
MN
01
—
R 170201-9
RN LICENSE
MN
Enumeration date
11/17/2015
Last updated
11/14/2018
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