Kimberly Marie Wagner, AT

Primary specialty

Athletic TrainerTaxonomy code 2255A2300X

License

AT002993 Issued in GA

Practice address

59 Executive Park S Ste 1100
Atlanta, GA 30329-2208

Phone

(404) 778-6330

Fax

(404) 778-6370

NPI assigned

Aug 2, 2017

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1501632000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1501632000000",
    "number": "1124542980",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8259 WICKER AVE",
            "city": "SAINT JOHN",
            "state": "IN",
            "postal_code": "463738878",
            "telephone_number": "219-635-6560",
            "fax_number": "219-365-6561"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "59 EXECUTIVE PARK S STE 1100",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303292208",
            "telephone_number": "404-778-6330",
            "fax_number": "404-778-6370"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WAGNER",
        "first_name": "KIMBERLY",
        "middle_name": "MARIE",
        "credential": "AT",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2017-08-02",
        "last_updated": "2017-08-02",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2255A2300X",
            "taxonomy_group": "",
            "desc": "Specialist/Technologist, Athletic Trainer",
            "state": "GA",
            "license": "AT002993",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GEORGIA BOARD OF AT",
            "identifier": "AT002993",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Brenda J Wagner, PHD
• Elivia Wagner, PA-C
• Eric R Wagner, MD
• Hannah Wagner
• John David Wagner, MD
• Lynn Wagner, MA, LPC
• Michele Suzanne Wagner, CSW
• Myesha J. Wagner, FNP-C
• Rebecca Nancy Wagner
• Riley Ann Wagner, OT

• Athletic Trainer in Atlanta, GA
• Providers in Atlanta, GA by specialty
• Athletic Trainer in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 2, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.