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General NPI Number Information
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NPI Number | 1821620451
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Entity Type | Individual
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Provider Name | KEVIN WAGNER FNP
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Gender | Male
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Dates
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Enumeration Date | 02/11/2020
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Last Update Date | 04/17/2024
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Provider Practice Location Address
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Address Line | 1001 BLYTHE BLVD STE 300- ADULT CARDIOLOGY
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City | CHARLOTTE
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State | NC
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Zip | 28203-5866
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Country | US
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Telephone | 704-373-0212
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 19305
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City | CHARLOTTE
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State | NC
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Zip | 28219-9305
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 2021021010
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 204420
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License Number State | OK
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Taxonomy #3
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 5012830
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License Number State | NC
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