Provider Demographics
NPI:1568477958
Name:WAGGONER, LISA C (CRNA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:C
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:C
Other - Last Name:PIC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:13130 N. 73RD PLAZA
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68122-1971
Mailing Address - Country:US
Mailing Address - Phone:402-552-3022
Mailing Address - Fax:402-552-3266
Practice Address - Street 1:16901 LAKESIDE HILLS CT
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130
Practice Address - Country:US
Practice Address - Phone:402-552-3022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE100855367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE277832Medicare ID - Type Unspecified