Healthcare Provider Details

I. General information

NPI: 1568477958
Provider Name (Legal Business Name): LISA C WAGGONER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA C PIC CRNA

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 06/02/2024
Certification Date: 06/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16901 LAKESIDE HILLS CT
OMAHA NE
68130
US

IV. Provider business mailing address

13130 N. 73RD PLAZA
OMAHA NE
68122-1971
US

V. Phone/Fax

Practice location:
  • Phone: 402-552-3022
  • Fax:
Mailing address:
  • Phone: 402-552-3022
  • Fax: 402-552-3266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number100855
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: