Provider Demographics
NPI:1700940830
Name:WAGNER, KRISTY MICHELLE (PA)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:MICHELLE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1940 ALCOA HWY
Mailing Address - Street 2:SUITE 120
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-2244
Mailing Address - Country:US
Mailing Address - Phone:865-305-8040
Mailing Address - Fax:865-305-8041
Practice Address - Street 1:1940 ALCOA HWY
Practice Address - Street 2:SUITE 120
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-2244
Practice Address - Country:US
Practice Address - Phone:865-305-8040
Practice Address - Fax:865-305-8041
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA938363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1510179Medicaid
TNQ20402Medicare UPIN
TN3662496Medicare ID - Type Unspecified