Provider Demographics
NPI:1457862435
Name:WAGNER, NINA E (CRNP)
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:E
Last Name:WAGNER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:NINA
Other - Middle Name:E
Other - Last Name:KANTOR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNP
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-8710
Mailing Address - Fax:414-805-1101
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-8710
Practice Address - Fax:414-805-1101
Is Sole Proprietor?:No
Enumeration Date:2017-10-18
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11521363LG0600X
PASP018002363LG0600X
MT160169363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1457862435Medicaid