Provider Demographics
NPI:1194739524
Name:WYGONIK, ADRENNE M (CRNA)
Entity type:Individual
Prefix:MS
First Name:ADRENNE
Middle Name:M
Last Name:WYGONIK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3035 LINDENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48120-1311
Mailing Address - Country:US
Mailing Address - Phone:313-441-3083
Mailing Address - Fax:
Practice Address - Street 1:3079 PEACHTREE INDUSTRIAL BLVD
Practice Address - Street 2:ANESTHESIA HEALTHCARE PARTNERS/HBL ANESTHESIA SERVICES
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-2215
Practice Address - Country:US
Practice Address - Phone:678-713-5847
Practice Address - Fax:770-945-5960
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704098999367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104323298Medicaid
MIAW098999OtherBLUE CROSS OF MI
MIAW098999OtherBLUE CROSS OF MI
MI4300666694Medicare ID - Type UnspecifiedRAILROAD MEDICARE