NPIMap

Individual provider Active NPI

Clarence Hughes Wagoner Jr., CRNA

  • Certified Registered Nurse Anesthetist
  • Kenansville, NC
National Provider Identifier
1235126400
Registry record updated Aug 24, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
Certified Registered Nurse AnesthetistTaxonomy code 367500000X
License
059528 Issued in NC
Practice address
401 N. Main St.
Kenansville, NC 28349-0278
Phone
(910) 296-2608
Fax
(910) 296-1174
NPI assigned
Oct 4, 2005
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Aug 24, 2009

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Certified Registered Nurse Anesthetist 367500000X 059528 NC Primary

Addresses

Primary practice location

401 N. Main St.
Kenansville, NC 28349-0278

Mailing address

PO Box 278
Kenansville, NC 28349-0278
Phone (910) 296-2608

Other identifiers 1

IdentifierTypeStateIssuer
8051164MedicaidNC

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled

State licenses

LicenseStateTypeSpecialty
059528NCMDCertified Registered Nurse Anesthetist

Practice roles

OrganizationSpecialtyStatusNew patients
Florida Anesthesia Associates P a Past Accepting new patients
Christian L Koppel MD PA Past Accepting new patients
North Florida Anesthesia Consultants, Inc. Past Accepting new patients
Lenoir Memorial Hospital, Incorporated Past Accepting new patients
Lenoir Memorial Hospital, Incorporated Nurse Anesthetist, Certified Registered Past Accepting new patients
Baptist Medical Center of the Beaches, Inc Past Accepting new patients

Organizations & group practices 6

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1128384000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1251072000000",
    "number": "1235126400",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 278",
            "city": "KENANSVILLE",
            "state": "NC",
            "postal_code": "283490278",
            "telephone_number": "910-296-2608",
            "fax_number": "910-296-1174"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "401 N. MAIN ST.",
            "city": "KENANSVILLE",
            "state": "NC",
            "postal_code": "283490278",
            "telephone_number": "910-296-2608",
            "fax_number": "910-296-1174"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WAGONER",
        "first_name": "CLARENCE",
        "middle_name": "HUGHES",
        "name_prefix": "Mr.",
        "name_suffix": "Jr.",
        "credential": "CRNA",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-10-04",
        "last_updated": "2009-08-24",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "367500000X",
            "taxonomy_group": "",
            "desc": "Nurse Anesthetist, Certified Registered",
            "state": "NC",
            "license": "059528",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8051164",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Kenansville, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 24, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.