Individual
MR. BRIAN GEORGE WAGONER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
RN, FNP BC
Contact information
Practice address
1235 E CHEROKEE ST, SPRINGFIELD, MO 65804-2203
(417) 820-9729
(417) 820-6471
Mailing address
PO BOX 2580, SPRINGFIELD, MO 65801-2580
(417) 829-4620
(417) 829-4312
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
155580
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
PENDING
—
MO
Enumeration date
01/12/2009
Last updated
06/10/2009
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