Provider Demographics
NPI:1053433474
Name:WAGNER, KERI JEAN (NP)
Entity type:Individual
Prefix:MRS
First Name:KERI
Middle Name:JEAN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 COMMACK RD
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-5404
Mailing Address - Country:US
Mailing Address - Phone:631-623-4000
Mailing Address - Fax:631-864-2787
Practice Address - Street 1:650 COMMACK RD
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-5404
Practice Address - Country:US
Practice Address - Phone:631-623-4000
Practice Address - Fax:631-864-2787
Is Sole Proprietor?:No
Enumeration Date:2007-04-05
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF334793363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily