Provider Demographics
NPI:1346083219
Name:WAQUONG, ANDENUM AMOS (DNP, PHN, FNP-C)
Entity type:Individual
Prefix:DR
First Name:ANDENUM
Middle Name:AMOS
Last Name:WAQUONG
Suffix:
Gender:M
Credentials:DNP, PHN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5210 PORCHLIGHT BAY
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-3700
Mailing Address - Country:US
Mailing Address - Phone:706-619-9010
Mailing Address - Fax:
Practice Address - Street 1:2730 COUNTY ROAD E E
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-4963
Practice Address - Country:US
Practice Address - Phone:651-777-6816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-17
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11769363L00000X, 363LF0000X
MN2310523163W00000X
GARN262014163W00000X, 363LF0000X
CA95283925163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily