Provider Demographics
NPI:1528030590
Name:WAGMAN, ELIZABETH (CRNA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:WAGMAN
Suffix:
Gender:F
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 157
Mailing Address - Street 2:
Mailing Address - City:GRAPEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15634-0157
Mailing Address - Country:US
Mailing Address - Phone:724-527-6517
Mailing Address - Fax:724-527-6519
Practice Address - Street 1:600 JEFFERSON AVE
Practice Address - Street 2:MERCY JEANNETTE HOSPITAL
Practice Address - City:JEANNETTE
Practice Address - State:PA
Practice Address - Zip Code:15644-0600
Practice Address - Country:US
Practice Address - Phone:724-527-3551
Practice Address - Fax:724-527-6519
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN144273L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA632763OtherBLUE SHIELD
WA632763OtherBLUE SHIELD