MEDICARE: DR. KATHRYN ANN WAGNER DC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	2017013442	MO

General Provider Information

NPI Number	:	1427584564
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KATHRYN ANN WAGNER DC

Provider Business Mailing Address
First Line	:	838 BROOKMEAD DR
Second Line	:
City	:	O FALLON
State	:	MO
Zip	:	63366-7572
Country	:	US
Telephone Number	:	314-606-8044
Fax Number	:

Provider Business Practice Location Address
First Line	:	15945 CLAYTON RD STE 230C
Second Line	:
City	:	BALLWIN
State	:	MO
Zip	:	63011-2491
Country	:	US
Telephone Number	:	636-256-5200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/10/2017
Last Update Date	:	02/07/2022

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