MEDICARE: MRS. CAITLYN CLARE WAGENBACH PA-C

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	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1346856846
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CAITLYN CLARE WAGENBACH PA-C

Provider Business Mailing Address
First Line	:	PO BOX 19248
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62794-9248
Country	:	US
Telephone Number	:	217-528-7541
Fax Number	:

Provider Business Practice Location Address
First Line	:	4616 N PROSPECT RD
Second Line	:
City	:	PEORIA HEIGHTS
State	:	IL
Zip	:	61616-6460
Country	:	US
Telephone Number	:	217-528-7541
Fax Number	:

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

Provider Enumeration Date	:	09/20/2020
Last Update Date	:	10/22/2024

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