MEDICARE: KATELYN WAGNER AGPCNP

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	363LA2200X	Adult Health Nurse Practitioner	312752	NY

General Provider Information

NPI Number	:	1871440180
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATELYN WAGNER AGPCNP

Provider Business Mailing Address
First Line	:	6740 SHAWNEE RD
Second Line	:
City	:	NORTH TONAWANDA
State	:	NY
Zip	:	14120-9504
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6740 SHAWNEE RD
Second Line	:
City	:	NORTH TONAWANDA
State	:	NY
Zip	:	14120-9504
Country	:	US
Telephone Number	:	716-903-7229
Fax Number	:

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

Provider Enumeration Date	:	03/16/2026
Last Update Date	:	03/16/2026

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