Provider Demographics
NPI:1275745309
Name:VANWAGONER, PATRICK READ (CRNA)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:READ
Last Name:VANWAGONER
Suffix:
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 1727
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84603-1727
Mailing Address - Country:US
Mailing Address - Phone:801-375-8049
Mailing Address - Fax:801-374-9195
Practice Address - Street 1:1067 N 500 W
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604
Practice Address - Country:US
Practice Address - Phone:801-375-8049
Practice Address - Fax:801-374-9195
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT191104-4406367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT562302331007Medicaid
UTR60918Medicare UPIN