MEDICARE: MICHELLE WAGGONER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	A-1409	NV

General Provider Information

NPI Number	:	1912671140
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE WAGGONER

Provider Business Mailing Address
First Line	:	9222 FOREST MEADOWS AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89149-0707
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3870 W ANN RD
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-4411
Country	:	US
Telephone Number	:	702-396-7100
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2021
Last Update Date	:	08/02/2021

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Directions to “ MICHELLE WAGGONER ” Practice Location

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