Keith Dineen Wagner, M.D.

Primary specialty

Dermatology PhysicianTaxonomy code 207N00000X

License

82425-20 Issued in WI

Practice address

3935 N Lightning Dr
Appleton, WI 54913-6717

Phone

(920) 968-1790

Fax

(920) 968-1794

NPI assigned

May 1, 2019

Sex

Male

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Electronic endpoints 2

Medicare fee-for-service enrollment

Enrolled in WI

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Specialty

Dermatology

Education

University of Texas Medical Branch at Galveston, 2015

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Forefront Dermatology SCGroup PAC ID 3779471701, 650 clinicians

Practice addresses (Care Compare)

Merit-based Incentive Payment System (MIPS)

Final score

97.45 of 100Reported as group

Promoting interoperability

97

Improvement activities

40

Procedures performed for Medicare patients

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: keith.wagner@forefrontdermatology.emadirect.md

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Forefront Dermatology, S.C.

  • Dermatology Physician
  • Appleton, WI
  • NPI 1083768253
  Medicare reassignment Care Compare group NPD
• Forefront Dermatology, S.C.

  • Dermatopathology Physician
  • Manitowoc, WI
  • NPI 1487969507
  NPD
• Forefront Dermatology, S.C.

  • Dermatology Physician
  • Columbus, OH
  • NPI 1063365385
  NPD
• Forefront Dermatology, S.C.

  • Dermatology Physician
  • Manitowoc, WI
  • NPI 1578515904
  NPD (past)
• Forefront Dermatology, S.C.

  • Dermatology Physician
  • Colorado Springs, CO
  • NPI 1881305084
  NPD (past)

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

{
    "created_epoch": "1556668800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1694390400000",
    "number": "1760047112",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "801 YORK ST",
            "city": "MANITOWOC",
            "state": "WI",
            "postal_code": "542204630",
            "telephone_number": "920-663-9008"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3935 N LIGHTNING DR",
            "city": "APPLETON",
            "state": "WI",
            "postal_code": "549136717",
            "telephone_number": "920-968-1790",
            "fax_number": "920-968-1794"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "2700 Crooks Ave Ste 101",
            "address_purpose": "LOCATION",
            "city": "Kaukauna",
            "state": "WI",
            "postal_code": "541303900",
            "country_code": "US",
            "telephone_number": "920-581-5561",
            "fax_number": "920-785-5511",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WAGNER",
        "first_name": "KEITH",
        "middle_name": "DINEEN",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2019-05-01",
        "last_updated": "2023-09-11",
        "certification_date": "2023-09-11",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": "WI",
            "license": "82425-20",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "Keith.Wagner@forefrontdermatology.emadirect.md",
            "affiliation": "N",
            "address_1": "2700 Crooks Ave Ste 101",
            "city": "Kaukauna",
            "state": "WI",
            "country_code": "US",
            "postal_code": "541303900",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "Keith.Wagner@forefrontdermatology.emadirect.md",
            "affiliation": "N",
            "address_1": "3935 N Lightning Dr",
            "city": "Appleton",
            "state": "WI",
            "country_code": "US",
            "postal_code": "549136717",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Wagner Wellness LLC
• Christopher T Wagner, MD
• Courtney Lynn Wagner, LAT, ATC
• Jody Michelle Wagner, D.C.
• Kaelyn Wagner, DPT
• Michael Ryan Wagner, D.C.
• Ryan J Wagner
• Timothy John Wagner, D.C., B.S.
• Wal-Mart Stores Easst, LP
• Wal-Mart Stores East LP

• Dermatology Physician in Appleton, WI
• Providers in Appleton, WI by specialty
• Dermatology Physician in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 11, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.