Provider Demographics
NPI:1992821789
Name:WAGNER, KIMBERLY D (PA-C)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:D
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 1:3071 S GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:MO
Mailing Address - Zip Code:64836-7851
Mailing Address - Country:US
Mailing Address - Phone:417-358-4811
Mailing Address - Fax:417-358-4781
Practice Address - Street 1:3071 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:MO
Practice Address - Zip Code:64836-7851
Practice Address - Country:US
Practice Address - Phone:417-358-4811
Practice Address - Fax:417-358-4781
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004003094363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
151410003Medicare PIN