Provider Demographics
NPI:1598328247
Name:WAGNER, KAITLIN PAIGE (MD)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:PAIGE
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 1:5547 EDWARDS RANCH RD APT 4111
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4182
Mailing Address - Country:US
Mailing Address - Phone:318-393-0236
Mailing Address - Fax:
Practice Address - Street 1:1250 8TH AVE STE 430
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4144
Practice Address - Country:US
Practice Address - Phone:817-923-0023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-18
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXU2352207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics