Individual
MR. CLARENCE HUGHES WAGONER JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
401 N. MAIN ST., KENANSVILLE, NC 28349-0278
(910) 296-2608
(910) 296-1174
Mailing address
PO BOX 278, KENANSVILLE, NC 28349-0278
(910) 296-2608
(910) 296-1174
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
059528
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
8051164
—
NC
Enumeration date
10/04/2005
Last updated
08/24/2009
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