Provider Demographics
NPI:1033900089
Name:WAGNON, BRIAN WILLIAM (RN)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:WILLIAM
Last Name:WAGNON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3374 E 550
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74352-7848
Mailing Address - Country:US
Mailing Address - Phone:918-232-2980
Mailing Address - Fax:
Practice Address - Street 1:1011 HONOR HEIGHTS DR
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-1318
Practice Address - Country:US
Practice Address - Phone:888-397-8387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-16
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK206468163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse