Individual
DR. KELLY E VAN WAGNER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
6380 N. DECATUR BLVD, STE 215, N. LAS VEGAS, NV 89084
(702) 948-1145
(702) 949-6206
Mailing address
6355 S BUFFALO DR FL 3, LAS VEGAS, NV 89113-2133
(702) 216-3346
(702) 671-6883
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
9533
NV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1306035571
SMA MEDICAID
NV
05
—
1306035571
—
NV
01
—
9533
STATE LICENSE
NV
01
—
V114112
SMA MEDICARE
NV
Enumeration date
10/23/2007
Last updated
02/13/2023
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