Provider Demographics
NPI:1093749731
Name:DEAN-WAGONER, JO ELLEN (CRNA)
Entity Type:Individual
Prefix:
First Name:JO
Middle Name:ELLEN
Last Name:DEAN-WAGONER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302-3351
Mailing Address - Country:US
Mailing Address - Phone:304-388-2470
Mailing Address - Fax:
Practice Address - Street 1:800 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-3351
Practice Address - Country:US
Practice Address - Phone:304-388-2470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAPRN27802-CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered