MEDICARE: DR. WILLIAM ROBERT WAGNER DRNP, LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	R055430	NY
2	163W00000X	Registered Nurse	541137	NY
3	363LA2200X	Adult Health Nurse Practitioner	F304782	NY
4	363LG0600X	Gerontology Nurse Practitioner	F340615	NY

General Provider Information

NPI Number	:	1043219587
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WILLIAM ROBERT WAGNER DRNP, LCSW

Provider Business Mailing Address
First Line	:	1000 HEALTH CENTER ROAD
Second Line	:	KYLE HEALTH CENTER / DHHS/IHS
City	:	KYLE
State	:	SD
Zip	:	57752
Country	:	US
Telephone Number	:	917-626-9011
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 HEALTH CENTER ROAD
Second Line	:	KYLE HEALTH CENTER / DHHS/IHS
City	:	KYLE
State	:	SD
Zip	:	57752
Country	:	US
Telephone Number	:	917-626-9011
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2005
Last Update Date	:	04/29/2016

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