Provider Demographics
NPI:1750659777
Name:WAGNER, CASEY RAE (APRN)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:RAE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 HEARTLAND RD
Mailing Address - Street 2:STE. 2800
Mailing Address - City:ST. JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-6201
Mailing Address - Country:US
Mailing Address - Phone:816-271-1200
Mailing Address - Fax:
Practice Address - Street 1:5325 FARAON ST.
Practice Address - Street 2:
Practice Address - City:ST. JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-3488
Practice Address - Country:US
Practice Address - Phone:816-271-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-05
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011028689363LX0001X
KS75395363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1750659777Medicaid
KS200750820AMedicaid
MO1750659777Medicaid