Provider Demographics
NPI:1558384875
Name:WAGNER, WILLIAM (CRNA)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:
Last Name:WAGNER
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 1:1710 CHEYENNE DR
Mailing Address - Street 2:
Mailing Address - City:HILLSBOROUGH
Mailing Address - State:NC
Mailing Address - Zip Code:27278-9500
Mailing Address - Country:US
Mailing Address - Phone:919-619-4998
Mailing Address - Fax:
Practice Address - Street 1:1710 CHEYENNE DR
Practice Address - Street 2:
Practice Address - City:HILLSBOROUGH
Practice Address - State:NC
Practice Address - Zip Code:27278-9500
Practice Address - Country:US
Practice Address - Phone:919-619-4998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC109814367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8050655Medicaid
NC8050655Medicaid