Provider Demographics
NPI:1750099008
Name:WAGNER, TARA (MSN, APRN, FNP-C)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MSN, APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 KY HIGHWAY 36 E
Mailing Address - Street 2:
Mailing Address - City:CYNTHIANA
Mailing Address - State:KY
Mailing Address - Zip Code:41031-7498
Mailing Address - Country:US
Mailing Address - Phone:859-234-2300
Mailing Address - Fax:
Practice Address - Street 1:1210 KY HWY 36 E
Practice Address - Street 2:
Practice Address - City:CYNTHIANA
Practice Address - State:KY
Practice Address - Zip Code:41031
Practice Address - Country:US
Practice Address - Phone:859-234-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-07
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3018825363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily