Healthcare Provider Details

I. General information

NPI: 1043219587
Provider Name (Legal Business Name): WILLIAM ROBERT WAGNER DRNP, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 04/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 HEALTH CENTER ROAD KYLE HEALTH CENTER / DHHS/IHS
KYLE SD
57752
US

IV. Provider business mailing address

1000 HEALTH CENTER ROAD KYLE HEALTH CENTER / DHHS/IHS
KYLE SD
57752
US

V. Phone/Fax

Practice location:
  • Phone: 917-626-9011
  • Fax:
Mailing address:
  • Phone: 917-626-9011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR055430
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number541137
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF304782
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberF340615
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: