Individual
ERIC DAVID WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
405 W JACKSON ST, CARBONDALE, IL 62901-1462
(618) 549-0721
(618) 529-0449
Mailing address
PO BOX 3988, CARBONDALE, IL 62902-3988
(618) 457-5200
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
209016825
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
118877
NBCRNA
IL
Enumeration date
10/30/2017
Last updated
03/05/2021
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