Provider Demographics
NPI:1932379344
Name:KATHLEEN T. WAGNER, MD, PC
Entity type:Organization
Organization Name:KATHLEEN T. WAGNER, MD, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:T
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-364-9988
Mailing Address - Street 1:PO BOX 81348
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89180-1348
Mailing Address - Country:US
Mailing Address - Phone:702-364-9988
Mailing Address - Fax:702-364-0880
Practice Address - Street 1:3120 S RAINBOW BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-6236
Practice Address - Country:US
Practice Address - Phone:702-364-9988
Practice Address - Fax:702-364-0880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9669207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVF95382Medicare UPIN
NVV38371Medicare PIN