Provider Demographics
NPI:1568450047
Name:WAGNER, CATHERINE B (CRNA)
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:B
Last Name:WAGNER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:CATHERINE
Other - Middle Name:B
Other - Last Name:STALFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 17978
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-7978
Mailing Address - Country:US
Mailing Address - Phone:804-288-4453
Mailing Address - Fax:804-288-1621
Practice Address - Street 1:7640 E PARHAM RD
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23294-4300
Practice Address - Country:US
Practice Address - Phone:804-285-4763
Practice Address - Fax:804-288-8946
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024166044367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010086051Medicaid
VA010086051Medicaid