Provider Demographics
NPI:1114593852
Name:WAGNER, KATHRYN CLARE (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:CLARE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:CLARE
Other - Last Name:STEENBERGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-685-9483
Mailing Address - Fax:614-685-0518
Practice Address - Street 1:460 W 10TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1240
Practice Address - Country:US
Practice Address - Phone:614-685-9483
Practice Address - Fax:614-685-0518
Is Sole Proprietor?:No
Enumeration Date:2021-06-02
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.006912RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0453033Medicaid