Provider Demographics
NPI:1598017048
Name:WAGNER, KRISTEN M (DO)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:M
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1675 LEAHY ST
Mailing Address - Street 2:SUITE 315A
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442-5500
Mailing Address - Country:US
Mailing Address - Phone:231-727-5209
Mailing Address - Fax:231-672-2901
Practice Address - Street 1:3443 FARR RD
Practice Address - Street 2:
Practice Address - City:FRUITPORT
Practice Address - State:MI
Practice Address - Zip Code:49415-8779
Practice Address - Country:US
Practice Address - Phone:231-672-2900
Practice Address - Fax:231-672-2901
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-09
Last Update Date:2020-12-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5101020125207Q00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology