Active NPI
Kimberly N Wagner, DPT
- Pediatric Physical Therapist
- Henderson, NV
National Provider Identifier
1104176593
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatric Physical Therapist
- License
- 2757
- Practice address
- 750 Coronado Center Dr
Suite 120
Henderson, NV 89052-5034 - Phone
- (702) 564-4116
- NPI assigned
- Sep 13, 2012
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatric Physical Therapist | 2251P0200X | 2757 | NV | Primary |
Addresses
Primary practice location
750 Coronado Center Dr
Suite 120
Henderson, NV 89052-5034
Mailing address
6617 Sunset Pines St
Las Vegas, NV 89148-4251
Phone (903) 453-1709
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2757 | NV | MD | Pediatric Physical Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1347494400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1569801600000",
"number": "1104176593",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "6617 SUNSET PINES ST",
"city": "LAS VEGAS",
"state": "NV",
"postal_code": "891484251",
"telephone_number": "903-453-1709"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "750 CORONADO CENTER DR",
"address_2": "SUITE 120",
"city": "HENDERSON",
"state": "NV",
"postal_code": "890525034",
"telephone_number": "702-564-4116"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WAGNER",
"first_name": "KIMBERLY",
"middle_name": "N",
"name_prefix": "Dr.",
"credential": "DPT",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2012-09-13",
"last_updated": "2019-09-30",
"status": "A"
},
"taxonomies": [
{
"code": "2251P0200X",
"taxonomy_group": "",
"desc": "Physical Therapist, Pediatrics",
"state": "NV",
"license": "2757",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Henderson, NV
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 30, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.