Provider Demographics
NPI:1699842229
Name:WAGNER, GARY L (CRNA)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:L
Last Name:WAGNER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7058 N MADELLAINE DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-7108
Mailing Address - Country:US
Mailing Address - Phone:253-334-3886
Mailing Address - Fax:
Practice Address - Street 1:16010 E INDIANA AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1813
Practice Address - Country:US
Practice Address - Phone:509-928-8040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00094715163W00000X, 367500000X
ID60628367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0124415OtherL & I
WA9610098Medicaid
WAWA5338OtherREGENCE
WA100378OtherL & I
WA0124415OtherL & I
WAAB06134Medicare ID - Type Unspecified
WAAB05133Medicare ID - Type Unspecified