Provider Demographics
NPI:1093154122
Name:WAGNER, KIMBERLY (DO)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1447 N HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-4727
Mailing Address - Country:US
Mailing Address - Phone:989-583-6000
Mailing Address - Fax:
Practice Address - Street 1:2970 PIERCE RD
Practice Address - Street 2:SUITE 2
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-8810
Practice Address - Country:US
Practice Address - Phone:989-583-0295
Practice Address - Fax:989-583-0299
Is Sole Proprietor?:No
Enumeration Date:2013-06-21
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101020682207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine