Provider Demographics
NPI:1861451155
Name:WAGNER, KATE (OD)
Entity Type:Individual
Prefix:DR
First Name:KATE
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12670 NEW BRITTANY BLVD
Mailing Address - Street 2:STE 102
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-3650
Mailing Address - Country:US
Mailing Address - Phone:239-936-2020
Mailing Address - Fax:239-936-2776
Practice Address - Street 1:12670 NEW BRITTANY BLVD
Practice Address - Street 2:STE 102
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3650
Practice Address - Country:US
Practice Address - Phone:239-936-2020
Practice Address - Fax:239-936-2776
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3840152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist