Provider Demographics
NPI:1205105624
Name:WAGNER, KRISTIN DIANE (APRN)
Entity type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:DIANE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:915 W MAPLE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:KS
Mailing Address - Zip Code:66725
Mailing Address - Country:US
Mailing Address - Phone:620-429-4988
Mailing Address - Fax:620-429-4978
Practice Address - Street 1:915 W MAPLE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:KS
Practice Address - Zip Code:66725
Practice Address - Country:US
Practice Address - Phone:620-429-4988
Practice Address - Fax:620-429-4978
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-14
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-75551-121363LF0000X
KS53-75551-21363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSKA3055002Medicare Oscar/Certification