| NPI | 1760826788 |
|---|---|
| Former Name | KELLY WAGNER |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0202X Radiology, Diagnostic Radiology (Licence: TN 56815) |
| Additional Taxonomies | 2085R0202X Radiology, Diagnostic Radiology (Licence: MS 25927) |
| 2085R0204X Radiology, Vascular & Interventional Radiology (Licence: TN 56815) | |
| 2085R0204X Radiology, Vascular & Interventional Radiology (Licence: MS 25927) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2013-04-21 |
| Last Update Date | 2019-05-30 |