Healthcare Provider Details

I. General information

NPI: 1992821789
Provider Name (Legal Business Name): KIMBERLY D WAGNER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 09/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3071 S GRAND AVE
CARTHAGE MO
64836-7851
US

IV. Provider business mailing address

3071 S GRAND AVE
CARTHAGE MO
64836-7851
US

V. Phone/Fax

Practice location:
  • Phone: 417-358-4811
  • Fax: 417-358-4781
Mailing address:
  • Phone: 417-358-4811
  • Fax: 417-358-4781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2004003094
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: