Individual
KATHLEEN THERESE WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
4920 W LONE MOUNTAIN RD, LAS VEGAS, NV 89130
(702) 655-0550
(702) 655-0545
Mailing address
PO BOX 98978, LAS VEGAS, NV 89193-8978
(702) 216-3346
(702) 671-6883
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
9669
NV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
002018691
—
NV
05
—
1952342933
—
NV
01
—
9669
STATE LICENSE
NV
Enumeration date
06/09/2006
Last updated
08/20/2018
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