Healthcare Provider Details

I. General information

NPI: 1699602458
Provider Name (Legal Business Name): MR. RYAN SIMENE WAGGONER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2026
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 N CAMPBELL AVE
TUCSON AZ
85724-0001
US

IV. Provider business mailing address

5612 S 55TH LN
LAVEEN AZ
85339-1524
US

V. Phone/Fax

Practice location:
  • Phone: 520-626-7878
  • Fax:
Mailing address:
  • Phone: 602-814-2317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: