Provider Demographics
NPI:1336545854
Name:WAGGONER, SCOTT A (CRNA)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:A
Last Name:WAGGONER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 HARLEM RD
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-2754
Mailing Address - Country:US
Mailing Address - Phone:815-877-4848
Mailing Address - Fax:815-636-6125
Practice Address - Street 1:12222 MERIT DR STE 600
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75251-3294
Practice Address - Country:US
Practice Address - Phone:972-715-5000
Practice Address - Fax:972-715-9976
Is Sole Proprietor?:No
Enumeration Date:2014-11-11
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.425396163W00000X
IL209.012327367500000X, 367500000X
TX1138853367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400195826Medicare PIN
ILP01519324Medicare PIN