Provider Demographics
NPI:1225031909
Name:WEGNER, NATHAN T (MD)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:T
Last Name:WEGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5718 NE SAPPHIRE PL
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64064-1177
Mailing Address - Country:US
Mailing Address - Phone:816-718-2372
Mailing Address - Fax:
Practice Address - Street 1:5718 NE SAPPHIRE PL
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64064-1177
Practice Address - Country:US
Practice Address - Phone:816-718-2372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000153518174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO27335011OtherBCBS
MOP0002191OtherMEDICARE RR
MO3368114AMedicare ID - Type Unspecified
MO27335011OtherBCBS