Provider Demographics
NPI:1558349977
Name:SAGENDORF, VINCENT W (CRNA)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:W
Last Name:SAGENDORF
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 4659
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93403-4659
Mailing Address - Country:US
Mailing Address - Phone:805-786-4878
Mailing Address - Fax:805-597-8354
Practice Address - Street 1:10 SANTA ROSA ST
Practice Address - Street 2:STE. 201
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-5825
Practice Address - Country:US
Practice Address - Phone:805-544-7246
Practice Address - Fax:805-782-8097
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACRNA225174400000X
NVCRNA000317367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVS12588Medicare UPIN