Provider Demographics
NPI:1518943166
Name:WAGNER, KRISTIN ELIZABETH (MD)
Entity type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:ELIZABETH
Last Name:WAGNER
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 604350
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-4350
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2001 VAIL AVE STE 320
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1222
Practice Address - Country:US
Practice Address - Phone:704-333-0741
Practice Address - Fax:704-333-3356
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200301072208600000X
NC0301072208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891345GMedicaid
NCH64443Medicare UPIN
2021690Medicare PIN
NC2021690 AMedicare ID - Type UnspecifiedCTS MEDICARE NUMBER
H64443Medicare UPIN