Healthcare Provider Details

I. General information

NPI: 1356229876
Provider Name (Legal Business Name): JAMES WAGNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2025
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N RAINBOW BLVD
LAS VEGAS NV
89107-1082
US

IV. Provider business mailing address

100 S MARTIN LUTHER KING BLVD APT 1092
LAS VEGAS NV
89106-4345
US

V. Phone/Fax

Practice location:
  • Phone: 702-448-8145
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: