Provider Demographics
NPI:1043862345
Name:FOGARTY, JOHN WADE (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WADE
Last Name:FOGARTY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 KENWOOD PKWY APT 110
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-1131
Mailing Address - Country:US
Mailing Address - Phone:913-800-0446
Mailing Address - Fax:
Practice Address - Street 1:6500 EXCELSIOR BLVD
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55426-4700
Practice Address - Country:US
Practice Address - Phone:952-993-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR244208-0163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine