Provider Demographics
NPI:1871656462
Name:WAGNER, KRISTINE LEE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KRISTINE
Middle Name:LEE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8251 W BROWARD BLVD
Mailing Address - Street 2:STE 300
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-2703
Mailing Address - Country:US
Mailing Address - Phone:954-475-9535
Mailing Address - Fax:
Practice Address - Street 1:1400 E BOULDER ST STE 700
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5533
Practice Address - Country:US
Practice Address - Phone:719-364-3278
Practice Address - Fax:719-365-7668
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101686363A00000X
FLPA 9101686363AS0400X
COPA.000845363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK0575Medicare UPIN