Provider Demographics
NPI:1720275365
Name:CORT-WAGNER, DIANE KATHLEEN (RN, FNP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:KATHLEEN
Last Name:CORT-WAGNER
Suffix:
Gender:F
Credentials:RN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-4598
Mailing Address - Country:US
Mailing Address - Phone:541-276-0057
Mailing Address - Fax:
Practice Address - Street 1:622 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801-4598
Practice Address - Country:US
Practice Address - Phone:541-276-0057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-27
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR085075504N1 FNP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR085075504N1 FNP-PPOtherOREGON STATE BOARD OF NUR