=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750659777
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CASEY RAE WAGNER APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2011
-----------------------------------------------------
Last Update Date | 10/30/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5325 FARAON ST.
-----------------------------------------------------
City | ST. JOSEPH
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64506-3488
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-271-6000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 901 HEARTLAND RD STE. 2800
-----------------------------------------------------
City | ST. JOSEPH
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64506-6201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-271-1200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LX0001X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Nurse Practitioner
-----------------------------------------------------
License Number | 2011028689
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LX0001X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Nurse Practitioner
-----------------------------------------------------
License Number | 75395
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------