Healthcare Provider Details

I. General information

NPI: 1164732053
Provider Name (Legal Business Name): MARK B. WAGNER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2010
Last Update Date: 10/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

468 CADIEUX RD
GROSSE POINTE MI
48230-1507
US

IV. Provider business mailing address

468 CADIEUX RD
GROSSE POINTE MI
48230-1507
US

V. Phone/Fax

Practice location:
  • Phone: 248-577-3520
  • Fax: 248-577-3526
Mailing address:
  • Phone: 248-577-3520
  • Fax: 248-577-3526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704254851
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: