Provider Demographics
NPI:1649332461
Name:WAGAMON, CRAIG A (CRNA)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:A
Last Name:WAGAMON
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 1:206 8TH ST NW
Mailing Address - Street 2:
Mailing Address - City:VALLEY CITY
Mailing Address - State:ND
Mailing Address - Zip Code:58072
Mailing Address - Country:US
Mailing Address - Phone:701-550-9335
Mailing Address - Fax:
Practice Address - Street 1:206 8TH ST NW
Practice Address - Street 2:
Practice Address - City:VALLEY CITY
Practice Address - State:ND
Practice Address - Zip Code:58072
Practice Address - Country:US
Practice Address - Phone:701-550-9335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR29587367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND25761OtherBLUE CROSS BLUE SHIELD
WI1649332461Medicaid
ND13462Medicaid
WI1649332461Medicaid
WIP00932704Medicare Oscar/Certification