Provider Demographics
NPI:1053785840
Name:WAGNER, MATTHEW
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 GRANT BLVD W
Mailing Address - Street 2:
Mailing Address - City:WABASHA
Mailing Address - State:MN
Mailing Address - Zip Code:55981-1042
Mailing Address - Country:US
Mailing Address - Phone:651-565-5600
Mailing Address - Fax:
Practice Address - Street 1:1200 GRANT BLVD W
Practice Address - Street 2:
Practice Address - City:WABASHA
Practice Address - State:MN
Practice Address - Zip Code:55981
Practice Address - Country:US
Practice Address - Phone:651-565-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-17
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNP 4307363LF0000X
MNR 170201-9163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNCNP 4307OtherAPRN LICENSE
MNR 170201-9OtherRN LICENSE