Healthcare Provider Details

I. General information

NPI: 1801347554
Provider Name (Legal Business Name): GEORGE ANDREW WAGGONER CSFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2016
Last Update Date: 10/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2036 KRAMERIA ST
DENVER CO
80207-3929
US

IV. Provider business mailing address

2036 KRAMERIA ST
DENVER CO
80207-3929
US

V. Phone/Fax

Practice location:
  • Phone: 303-934-6970
  • Fax:
Mailing address:
  • Phone: 303-934-6970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License NumberSA.0001218
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: