Basic Information
| Provider Information | |||||||||
| NPI: | 1093156564 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | GWENYTH | ||||||||
| MiddleName: | GRACE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 405 S CLAIRBORNE RD STE 2 | ||||||||
| Address2: | |||||||||
| City: | OLATHE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660621774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9137303661 | ||||||||
| FaxNumber: | 9137681944 | ||||||||
| Practice Location | |||||||||
| Address1: | 407 S CLAIRBORNE RD | ||||||||
| Address2: | |||||||||
| City: | OLATHE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660621857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9133939921 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2013 | ||||||||
| LastUpdateDate: | 03/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 53-74969 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.