Basic Information
| Provider Information | |||||||||
| NPI: | 1427692631 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGNON | ||||||||
| FirstName: | SAMANTHA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 866 S REED CT APT F | ||||||||
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| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802264497 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3702 AUTOMATION WAY STE 103 | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805255738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702242985 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2019 | ||||||||
| LastUpdateDate: | 05/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 22583017 | CO | N | Nursing Service Providers | Registered Nurse | 367500000X | 126640 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.