Individual
DR. KELLY E VAN WAGNER
Active
Individual
DR. KELLY E VAN WAGNER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
M.D.
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
Update your record
If you believe information in your NPPES record is inaccurate, or if you wish to update or deactivate your NPI, you can do so directly with CMS at https://nppes.cms.hhs.gov.
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