Provider Demographics
NPI:1508370651
Name:WAGNON, CHRISTA M (RN, FNP)
Entity Type:Individual
Prefix:
First Name:CHRISTA
Middle Name:M
Last Name:WAGNON
Suffix:
Gender:F
Credentials:RN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3815 E BELL RD STE 2200
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-2139
Mailing Address - Country:US
Mailing Address - Phone:602-633-3884
Mailing Address - Fax:602-633-3841
Practice Address - Street 1:7330 N 99TH AVE STE 325
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85307-3022
Practice Address - Country:US
Practice Address - Phone:480-840-1769
Practice Address - Fax:480-840-1785
Is Sole Proprietor?:No
Enumeration Date:2017-11-28
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-03457363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM80301398Medicaid