Provider Demographics
NPI:1871804799
Name:WAGNON, AMBER R (ARNP)
Entity type:Individual
Prefix:MS
First Name:AMBER
Middle Name:R
Last Name:WAGNON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2135 N COLLECTIVE LN
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-3560
Mailing Address - Country:US
Mailing Address - Phone:316-261-3220
Mailing Address - Fax:316-261-3298
Practice Address - Street 1:2135 N COLLECTIVE LN
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-3560
Practice Address - Country:US
Practice Address - Phone:316-261-3220
Practice Address - Fax:316-261-3298
Is Sole Proprietor?:No
Enumeration Date:2010-06-25
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-75197363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200664490AMedicaid
KS200664490AMedicaid