| Doctor Name: | MRS. KERI JEAN WAGNER |
| NPI Number: | 1053433474 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | N.P. |
| License Number: | F334793 |
| Business Practice Address: | 650 Commack Rd Commack, NY - 117255404 |
| Business Phone Number: | 6316234000 |
| Business Fax Number: | 6318642787 |
| Mailing Address: | 650 Commack Rd, COMMACK |
| State: | NY |
| Postal Code: | 117255404 |
| Phone Number: | 6316234000 |
| Fax Number: | 6318642787 |
| NPI Enumeration Date: | 04/05/2007 |
| NPI Last Update Date: | 05/13/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LF0000X |
| License Number: | F334793 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NY |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Family |
| Taxonomy Definition: | |