Basic Information
| Provider Information | |||||||||
| NPI: | 1134523269 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | CASSIE | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BROOME | ||||||||
| OtherFirstName: | CASSIE | ||||||||
| OtherMiddleName: | J | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 403 1ST ST SE | ||||||||
| Address2: | |||||||||
| City: | BELMOND | ||||||||
| State: | IA | ||||||||
| PostalCode: | 504211201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6414443500 | ||||||||
| FaxNumber: | 5155329245 | ||||||||
| Practice Location | |||||||||
| Address1: | 840 W US HIGHWAY 18 | ||||||||
| Address2: | |||||||||
| City: | GARNER | ||||||||
| State: | IA | ||||||||
| PostalCode: | 504381023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6419251500 | ||||||||
| FaxNumber: | 6419251507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2014 | ||||||||
| LastUpdateDate: | 12/03/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | C112229 | IA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LP0200X | C112229 | IA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0222X | C112229 | IA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics, Critical Care | 363LP0200X | C156954 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.