Provider Demographics
NPI:1306035571
Name:VAN WAGNER, KELLY E (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:E
Last Name:VAN WAGNER
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:6355 S BUFFALO DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-2133
Mailing Address - Country:US
Mailing Address - Phone:702-216-3346
Mailing Address - Fax:702-671-6883
Practice Address - Street 1:6380 N. DECATUR BLVD
Practice Address - Street 2:STE 215
Practice Address - City:N. LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89084
Practice Address - Country:US
Practice Address - Phone:702-948-1145
Practice Address - Fax:702-949-6206
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-23
Last Update Date:2023-02-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NV9533207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV9533OtherSTATE LICENSE
NVV114112OtherSMA MEDICARE
NV1306035571Medicaid
NV1306035571OtherSMA MEDICAID