Provider Demographics
NPI:1083376750
Name:STAGNER, ILYA O (FNP-C)
Entity Type:Individual
Prefix:MR
First Name:ILYA
Middle Name:O
Last Name:STAGNER
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 CHEROKEE AVE
Mailing Address - Street 2:
Mailing Address - City:HIAWATHA
Mailing Address - State:KS
Mailing Address - Zip Code:66434-1608
Mailing Address - Country:US
Mailing Address - Phone:816-351-2897
Mailing Address - Fax:
Practice Address - Street 1:300 UTAH ST
Practice Address - Street 2:
Practice Address - City:HIAWATHA
Practice Address - State:KS
Practice Address - Zip Code:66434-2314
Practice Address - Country:US
Practice Address - Phone:785-742-6422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-11
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS80603363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner