Provider Demographics
NPI:1245490952
Name:WAGNER, JEWELIA (MD)
Entity type:Individual
Prefix:
First Name:JEWELIA
Middle Name:
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 1:1010 N KANSAS ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-3124
Mailing Address - Country:US
Mailing Address - Phone:316-962-3030
Mailing Address - Fax:
Practice Address - Street 1:6545 FRANCE AVE S STE 490
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435
Practice Address - Country:US
Practice Address - Phone:952-922-7600
Practice Address - Fax:952-345-4448
Is Sole Proprietor?:No
Enumeration Date:2008-06-16
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS7028207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology