Healthcare Provider Details

I. General information

NPI: 1932661402
Provider Name (Legal Business Name): ROBERTA LYNN HUNA WAGNER AG-CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 04/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E 28TH ST # MR 94100
MINNEAPOLIS MN
55407-3799
US

IV. Provider business mailing address

800 E 28TH ST # MR 94100
MINNEAPOLIS MN
55407-3799
US

V. Phone/Fax

Practice location:
  • Phone: 612-775-3582
  • Fax:
Mailing address:
  • Phone: 612-775-3582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License Number539
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: