Healthcare Provider Details

I. General information

NPI: 1952043689
Provider Name (Legal Business Name): JORDAN WAGNER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2022
Last Update Date: 04/12/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1117 E DEVONSHIRE AVE
HEMET CA
92543-3083
US

IV. Provider business mailing address

3477 AMBER LN
OCEANSIDE CA
92056-4844
US

V. Phone/Fax

Practice location:
  • Phone: 951-652-2811
  • Fax:
Mailing address:
  • Phone: 775-450-7238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number269194
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: