Provider Demographics
NPI:1043219587
Name:WAGNER, WILLIAM ROBERT (DRNP, LCSW)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:ROBERT
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DRNP, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 HEALTH CENTER ROAD
Mailing Address - Street 2:KYLE HEALTH CENTER / DHHS/IHS
Mailing Address - City:KYLE
Mailing Address - State:SD
Mailing Address - Zip Code:57752
Mailing Address - Country:US
Mailing Address - Phone:917-626-9011
Mailing Address - Fax:
Practice Address - Street 1:1000 HEALTH CENTER ROAD
Practice Address - Street 2:KYLE HEALTH CENTER / DHHS/IHS
Practice Address - City:KYLE
Practice Address - State:SD
Practice Address - Zip Code:57752
Practice Address - Country:US
Practice Address - Phone:917-626-9011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0554301041C0700X
NY541137163W00000X
NYF304782363LA2200X
NYF340615363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No163W00000XNursing Service ProvidersRegistered Nurse
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
S966N122Medicare PIN
Q59896Medicare UPIN