Basic Information
| Provider Information | |||||||||
| NPI: | 1235793100 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | JACQUELYN | ||||||||
| MiddleName: | CHRISTINE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 S SANTA FE AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SALINA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 674014189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858252273 | ||||||||
| FaxNumber: | 7858252275 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 S SANTA FE AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SALINA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 674014189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858252273 | ||||||||
| FaxNumber: | 7858252275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2019 | ||||||||
| LastUpdateDate: | 09/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | R77391 | AZ | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 0446272 | KS | N | Allopathic & Osteopathic Physicians | Pediatrics | 208M00000X | 04-46272 | KS | N | Allopathic & Osteopathic Physicians | Hospitalist | 208000000X | 04-46272 | KS | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 30004822670001 | 05 | KS | MEDICAID |