Provider Demographics
NPI:1093139131
Name:WAGNER, HILARY (CRNA, MSN)
Entity Type:Individual
Prefix:
First Name:HILARY
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:CRNA, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3190 CAMDEN DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-7022
Mailing Address - Country:US
Mailing Address - Phone:248-252-4704
Mailing Address - Fax:
Practice Address - Street 1:251 E. HURON
Practice Address - Street 2:FEINBERG 5‑704
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2908
Practice Address - Country:US
Practice Address - Phone:312-695-4146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-10
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041416829163W00000X
IL209011234367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse