Provider Demographics
NPI:1417667114
Name:WAGNER, KAREN ((R) RT, FCC)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:(R) RT, FCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:442 WATERVLIET AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45420-2467
Mailing Address - Country:US
Mailing Address - Phone:937-344-0110
Mailing Address - Fax:
Practice Address - Street 1:442 WATERVLIET AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45420-2467
Practice Address - Country:US
Practice Address - Phone:937-344-0110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-02
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH433896225500000X, 247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist
No225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist