MEDICARE: KATHLEEN T. WAGNER, MD, PC

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	207Q00000X	Family Medicine Physician	9669	NV

General Provider Information

NPI Number	:	1932379344
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KATHLEEN T. WAGNER, MD, PC

Provider Business Mailing Address
First Line	:	PO BOX 81348
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89180-1348
Country	:	US
Telephone Number	:	702-364-9988
Fax Number	:	702-364-0880

Provider Business Practice Location Address
First Line	:	3120 S RAINBOW BLVD
Second Line	:	SUITE 202
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-6236
Country	:	US
Telephone Number	:	702-364-9988
Fax Number	:	702-364-0880

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. KATHLEEN T. WAGNER
Credential	:	M.D.
Telephone Number	:	702-364-9988

Provider Enumeration Date	:	03/03/2008
Last Update Date	:	03/03/2008

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