Healthcare Provider Details

I. General information

NPI: 1093125478
Provider Name (Legal Business Name): KATHERINE ELIZABETH WAGNER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2014
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

168 N BRENT ST STE 408
VENTURA CA
93003-2824
US

IV. Provider business mailing address

168 N BRENT ST STE 408
VENTURA CA
93003-2824
US

V. Phone/Fax

Practice location:
  • Phone: 617-281-5273
  • Fax: 805-643-0672
Mailing address:
  • Phone: 617-281-5273
  • Fax: 805-643-0672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberA171941
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: