Provider Demographics
NPI:1235126400
Name:WAGONER, CLARENCE HUGHES JR (CRNA)
Entity Type:Individual
Prefix:MR
First Name:CLARENCE
Middle Name:HUGHES
Last Name:WAGONER
Suffix:JR
Gender:M
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 278
Mailing Address - Street 2:
Mailing Address - City:KENANSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28349-0278
Mailing Address - Country:US
Mailing Address - Phone:910-296-2608
Mailing Address - Fax:910-296-1174
Practice Address - Street 1:401 N. MAIN ST.
Practice Address - Street 2:
Practice Address - City:KENANSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28349-0278
Practice Address - Country:US
Practice Address - Phone:910-296-2608
Practice Address - Fax:910-296-1174
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC059528367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8051164Medicaid
NC2616579AMedicare ID - Type UnspecifiedMEDICARE BILLING #