Provider Demographics
NPI:1902837255
Name:WAGNER, KRISTINE TIFFANY (PHD)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:TIFFANY
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PHD
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 892143
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92589-2143
Mailing Address - Country:US
Mailing Address - Phone:951-695-7400
Mailing Address - Fax:951-695-7144
Practice Address - Street 1:27393 YNEZ RD
Practice Address - Street 2:SUITE 153
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-5604
Practice Address - Country:US
Practice Address - Phone:951-695-7400
Practice Address - Fax:951-695-7144
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18320103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WCP18320AMedicare ID - Type Unspecified
0PL183200Medicare ID - Type Unspecified
ZZZ01448ZMedicare ID - Type UnspecifiedNO. CAL GROUP ID NO.
P60902Medicare UPIN
W18386Medicare ID - Type UnspecifiedSO. CAL PROVIDER NUMBER