Provider Demographics
NPI:1073138624
Name:WAGONER, SARAH (APRN)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:WAGONER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 E ROUGH CREEK PL
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-8568
Mailing Address - Country:US
Mailing Address - Phone:620-210-0039
Mailing Address - Fax:
Practice Address - Street 1:9300 E 29TH ST N STE 204
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-2183
Practice Address - Country:US
Practice Address - Phone:316-500-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS5379450363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner