Healthcare Provider Details

I. General information

NPI: 1750379327
Provider Name (Legal Business Name): AMY ELIZABETH WAGAR RN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 CENTRAL AVE
PEARL HARBOR HI
96860-4908
US

IV. Provider business mailing address

2176 BANCROFT DR
KAILUA HI
96734-4812
US

V. Phone/Fax

Practice location:
  • Phone: 808-474-0625
  • Fax: 808-471-1855
Mailing address:
  • Phone: 808-474-0625
  • Fax: 808-471-1855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License NumberR24687
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: