Provider Demographics
NPI:1053389502
Name:VANWAGONER, JOHN ALLEN (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ALLEN
Last Name:VANWAGONER
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 1:6101 WINDCOM CT
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-7817
Mailing Address - Country:US
Mailing Address - Phone:972-398-3500
Mailing Address - Fax:972-398-3512
Practice Address - Street 1:6101 WINDCOM CT
Practice Address - Street 2:SUITE 400
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-7817
Practice Address - Country:US
Practice Address - Phone:972-398-3500
Practice Address - Fax:972-398-3512
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8854174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH65483Medicare UPIN