Provider Demographics
NPI:1578858999
Name:WAGONER, GEORGINE (ARNP)
Entity Type:Individual
Prefix:
First Name:GEORGINE
Middle Name:
Last Name:WAGONER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 INDEPENDENCE AVE
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50703-4300
Mailing Address - Country:US
Mailing Address - Phone:319-291-2413
Mailing Address - Fax:319-291-2659
Practice Address - Street 1:1407 INDEPENDENCE AVE
Practice Address - Street 2:5TH FLOOR
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50703-4300
Practice Address - Country:US
Practice Address - Phone:319-291-2413
Practice Address - Fax:319-291-2659
Is Sole Proprietor?:No
Enumeration Date:2011-06-14
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAC-041395363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics