Provider Demographics
NPI:1578766648
Name:WAGGLE, TAMERA (CRNA)
Entity Type:Individual
Prefix:
First Name:TAMERA
Middle Name:
Last Name:WAGGLE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 W FAIRVIEW ST
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:PA
Mailing Address - Zip Code:15501-1344
Mailing Address - Country:US
Mailing Address - Phone:814-445-4329
Mailing Address - Fax:814-534-9715
Practice Address - Street 1:1186 FRANKLIN ST.
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905
Practice Address - Country:US
Practice Address - Phone:814-534-9391
Practice Address - Fax:814-534-9715
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN301942L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered