Healthcare Provider Details

I. General information

NPI: 1689011405
Provider Name (Legal Business Name): NICOLE ANN WAGAMAN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2013
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 PLEASANT ST
DES MOINES IA
50309-1406
US

IV. Provider business mailing address

1200 PLEASANT ST
DES MOINES IA
50309-1406
US

V. Phone/Fax

Practice location:
  • Phone: 515-241-6907
  • Fax:
Mailing address:
  • Phone: 515-241-6907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR-9752
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number67461
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number87896
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code2081P0004X
TaxonomySpinal Cord Injury Medicine Physician
License Number331223
License Number StateLA
# 5
Primary TaxonomyY
Taxonomy Code2081P0004X
TaxonomySpinal Cord Injury Medicine Physician
License NumberDO-05546
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: