Individual
JERICA A WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
120 E HOSPITAL DR, ANGLETON, TX 77515-4112
(979) 849-2447
(979) 848-8337
Mailing address
120 E HOSPITAL DR, ANGLETON, TX 77515-4112
(979) 849-2447
(979) 848-8337
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00U38X
BCBS
TX
Enumeration date
11/05/2007
Last updated
11/05/2007
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