Provider Demographics
NPI:1164655452
Name:WAGONER, SHY L (CST)
Entity Type:Individual
Prefix:
First Name:SHY
Middle Name:L
Last Name:WAGONER
Suffix:
Gender:F
Credentials:CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2921 MONTVALE DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-5359
Mailing Address - Country:US
Mailing Address - Phone:217-787-2700
Mailing Address - Fax:217-787-2715
Practice Address - Street 1:2921 MONTVALE DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-5359
Practice Address - Country:US
Practice Address - Phone:217-787-2700
Practice Address - Fax:217-787-2715
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-02
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist