MEDICARE: KATHLEEN THERESE WAGNER MD

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	207Q00000X	Family Medicine Physician	9669	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9669	OTHER	NV	STATE LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1952342933
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN THERESE WAGNER MD

Provider Business Mailing Address
First Line	:	PO BOX 98978
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89193-8978
Country	:	US
Telephone Number	:	702-216-3346
Fax Number	:	702-671-6883

Provider Business Practice Location Address
First Line	:	4920 W LONE MOUNTAIN RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130
Country	:	US
Telephone Number	:	702-655-0550
Fax Number	:	702-655-0545

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

Provider Enumeration Date	:	06/09/2006
Last Update Date	:	08/20/2018

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