Basic Information
| Provider Information | |||||||||
| NPI: | 1962823252 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8906 SPANISH RIDGE AVE STE 202 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891481319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023303102 | ||||||||
| FaxNumber: | 7029124994 | ||||||||
| Practice Location | |||||||||
| Address1: | 517 ROSE ST | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891064020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024384692 | ||||||||
| FaxNumber: | 7024852372 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2014 | ||||||||
| LastUpdateDate: | 12/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APRN001621 | NV | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 367A00000X | APRN001621 | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
No ID Information.