Provider Demographics
NPI:1477948511
Name:WAGNER, KIRSTEN (MD)
Entity Type:Individual
Prefix:DR
First Name:KIRSTEN
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
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:PO BOX 62106
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93160-2106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4151 FOOTHILL RD
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93110-1110
Practice Address - Country:US
Practice Address - Phone:805-681-7500
Practice Address - Fax:805-681-1768
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-06
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2019-00782207W00000X
CAA168573207W00000X, 207WX0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0120XAllopathic & Osteopathic PhysiciansOphthalmologyCornea and External Diseases Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA168573OtherMEDICAL DEGREE