Provider Demographics
NPI:1043614597
Name:WAGNER, KAVITHA (CRNP)
Entity type:Individual
Prefix:MRS
First Name:KAVITHA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 MEMORY LN
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-2231
Mailing Address - Country:US
Mailing Address - Phone:717-851-1405
Mailing Address - Fax:
Practice Address - Street 1:1001 S GEORGE ST
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-3676
Practice Address - Country:US
Practice Address - Phone:717-851-3467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-13
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP014314363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner