Jon Van Wagoner
Specialist • Pocatello, ID
Notice of NPI Deactivation & Inactive Practice Status
According to official public domain records published by CMS (Centers for Medicare & Medicaid Services) in the National Provider Identifier (NPPES) Registry, Jon Van Wagoner has officially deactivated this NPI record and ceased active healthcare practice.
Professional Overview & Biography Verified Profile Summary
Jon Van Wagoner was a registered Specialist practicing in Pocatello, ID. Throughout an active medical career spanning 1 years, Jon Van Wagoner provided care at the practice location at 565 CREE AVE until profile deactivation on 2017-04-18.
Practice Location & Contact Primary Location
565 Cree Ave
Pocatello, ID 832043739
Specialty Benchmarks & Practice Insights
Comparative analytics for Specialist in Pocatello, ID
Practicing in Pocatello, ID (194 Statewide)
In-Person Office Visits Only
Under CMS Medicare Fee Schedule vs Standard Submitted Charges
Medical Specialties & State Licenses
NUCC Taxonomy Code: 174400000X
An individual educated and trained in an applied knowledge discipline used in the performance of work at a level requiring knowledge and skills beyond or apart from that provided by a general education or liberal arts degree.
Career & Practice History Timeline
Chronological log of verified NPI updates, location relocations, credentials, and registry changes
Record deactivated on April 18, 2017
NPI status registered as active in NPPES database
Registered at 565 CREE AVE, POCATELLO, ID 832043739 (Tel: 2082612445)
Registered at 565 CREE AVE, POCATELLO, ID 832043739
Recorded as JON VAN WAGONER
Specialist (License #L1536454208 in ID)
First registered as active Individual Practitioner in NPPES Database.
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Mailing Address
565 Cree Ave
Pocatello, ID 832043739
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