Basic Information
| Provider Information | |||||||||
| NPI: | 1578584819 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAAGEN | ||||||||
| FirstName: | GAIL | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | CNS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2168 | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581072168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012342110 | ||||||||
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| Practice Location | |||||||||
| Address1: | 801 BROADWAY N | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581023641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012345015 | ||||||||
| FaxNumber: | 7012347481 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2006 | ||||||||
| LastUpdateDate: | 11/14/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364S00000X | R13529 | ND | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist |
ID Information
| ID | Type | State | Issuer | Description | 70019 | 05 | ND | MEDICAID |