Basic Information
| Provider Information | |||||||||
| NPI: | 1821085879 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | CAROLE | ||||||||
| MiddleName: | EATON | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 206 | ||||||||
| Address2: | |||||||||
| City: | HUMBOLDT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863290206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286325550 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 500 HWY 89 NORTH | ||||||||
| Address2: | NORTHERN AZVA HEALTHCARE SYSTEM | ||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284454860 | ||||||||
| FaxNumber: | 9287766147 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2005 | ||||||||
| LastUpdateDate: | 10/26/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN036104 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.