1932379344 NPI number — KATHLEEN T. WAGNER, MD, PC

Table of content: (NPI 1932379344)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932379344 NPI number — KATHLEEN T. WAGNER, MD, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KATHLEEN T. WAGNER, MD, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PIONEER FAMILY MEDICINE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1932379344
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3120 S RAINBOW BLVD
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89146-6236
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-364-9988
Provider Business Practice Location Address Fax Number:
702-364-0880
Provider Enumeration Date:
03/03/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WAGNER
Authorized Official First Name:
KATHLEEN
Authorized Official Middle Name:
T.
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
702-364-9988

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  9669 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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