Provider Demographics
NPI:1659479723
Name:WAGONER, SHIRLEY G (ARNP)
Entity Type:Individual
Prefix:MS
First Name:SHIRLEY
Middle Name:G
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:PO BOX 197
Mailing Address - Street 2:
Mailing Address - City:IONE
Mailing Address - State:WA
Mailing Address - Zip Code:99139-0197
Mailing Address - Country:US
Mailing Address - Phone:509-442-3514
Mailing Address - Fax:509-442-3436
Practice Address - Street 1:208 CEDAR CREEK TERRACE
Practice Address - Street 2:
Practice Address - City:IONE
Practice Address - State:WA
Practice Address - Zip Code:99139-0197
Practice Address - Country:US
Practice Address - Phone:509-442-3514
Practice Address - Fax:509-442-3436
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60007062363LP2300X, 363LW0102X
WAAP30001501367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP35437Medicare UPIN