Basic Information
| Provider Information | |||||||||
| NPI: | 1043581770 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 249 | ||||||||
| Address2: | |||||||||
| City: | FORT ATKINSON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535380249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9205634466 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 611 SHERMAN AVE E | ||||||||
| Address2: | |||||||||
| City: | FORT ATKINSON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535381960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9205685000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2012 | ||||||||
| LastUpdateDate: | 10/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 190070-30 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.