MEDICARE: DR. KELLY E VAN WAGNER M.D.

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	207R00000X	Internal Medicine Physician	9533	NV

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	V114112	OTHER	NV	SMA MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9533	OTHER	NV	STATE LICENSE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306035571
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY E VAN WAGNER M.D.

Provider Business Mailing Address
First Line	:	6355 S BUFFALO DR FL 3
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89113-2133
Country	:	US
Telephone Number	:	702-216-3346
Fax Number	:	702-671-6883

Provider Business Practice Location Address
First Line	:	6380 N. DECATUR BLVD
Second Line	:	STE 215
City	:	N. LAS VEGAS
State	:	NV
Zip	:	89084
Country	:	US
Telephone Number	:	702-948-1145
Fax Number	:	702-949-6206

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

Provider Enumeration Date	:	10/23/2007
Last Update Date	:	02/13/2023

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Directions to “ DR. KELLY E VAN WAGNER M.D.” Practice Location

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