Provider Demographics
NPI:1992054431
Name:WAGNER, STACY L (PA-C)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 E 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:KS
Mailing Address - Zip Code:67156-5201
Mailing Address - Country:US
Mailing Address - Phone:620-221-9500
Mailing Address - Fax:620-221-3700
Practice Address - Street 1:1305 E 19TH AVE
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:KS
Practice Address - Zip Code:67156-5201
Practice Address - Country:US
Practice Address - Phone:620-221-9500
Practice Address - Fax:620-221-3700
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
15-01553363A00000X
KS15-01553363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant