Provider Demographics
NPI:1043862345
Name:FOGARTY, JOHN WADE (CRNA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:WADE
Last Name:FOGARTY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11333 HEMLOCK ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66210-2458
Mailing Address - Country:US
Mailing Address - Phone:913-800-0446
Mailing Address - Fax:
Practice Address - Street 1:4000 CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66160-4700
Practice Address - Country:US
Practice Address - Phone:913-588-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS43-557941-062367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered