Provider Demographics
NPI:1568408789
Name:WAGNER, ELLEN A (CRNA)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:A
Last Name:WAGNER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:455 TOLL GATE RD
Mailing Address - Street 2:PRC AND CREDENTIALING
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886
Mailing Address - Country:US
Mailing Address - Phone:401-273-0641
Mailing Address - Fax:401-273-2919
Practice Address - Street 1:265 HERRICK ROAD
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968
Practice Address - Country:US
Practice Address - Phone:631-726-8350
Practice Address - Fax:631-726-8519
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY3472891367500000X
RIAPRN03496367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00164249OtherRR MEDICARE
NYR3B431Medicare PIN