Provider Demographics
NPI:1275617854
Name:WAGAMAN, KRISTEN JEAN (ARNP)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:JEAN
Last Name:WAGAMAN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:JEAN
Other - Last Name:BOCKENSTEDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:75 SHORT ST NW
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52405-4203
Mailing Address - Country:US
Mailing Address - Phone:319-390-3223
Mailing Address - Fax:319-390-7532
Practice Address - Street 1:75 SHORT ST NW
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52405
Practice Address - Country:US
Practice Address - Phone:319-390-3223
Practice Address - Fax:319-390-7532
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA89760363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAQ74032Medicare UPIN
IAI18736Medicare PIN