Provider Demographics
NPI:1578125506
Name:WAGONER, HALEY
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:WAGONER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 HOSPITAL PL
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7559
Mailing Address - Country:US
Mailing Address - Phone:907-714-4130
Mailing Address - Fax:
Practice Address - Street 1:240 HOSPITAL PL STE 305
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7559
Practice Address - Country:US
Practice Address - Phone:907-714-4130
Practice Address - Fax:844-412-3946
Is Sole Proprietor?:No
Enumeration Date:2019-06-29
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty