Provider Demographics
NPI:1093881666
Name:WAGNER, MONA H (CRNA)
Entity Type:Individual
Prefix:
First Name:MONA
Middle Name:H
Last Name:WAGNER
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:PO BOX 714960
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43271-4960
Mailing Address - Country:US
Mailing Address - Phone:205-322-1808
Mailing Address - Fax:205-322-1851
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-273-8610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9418194367500000X
FLAPRN9418194367500000X
WV25214367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0207026000Medicaid
KY74008822Medicaid
OH2107900Medicaid
WVDF0767OtherRR MEDICARE
WV270052997002OtherTRICARE
WVP00001160OtherRR MEDICARE
OH23492135300OtherW/COMP
WVDA0096OtherRR MEDICARE
WV01706470OtherMSBCBS GROUP
FL117174600Medicaid
WV001721837OtherBCBS
WV0573001000Medicaid
WV1045609OtherW/COMP
WVP00241517OtherRR MEDICARE
WV8221936Medicare PIN
WV1045609OtherW/COMP