Healthcare Provider Details

I. General information

NPI: 1912285933
Provider Name (Legal Business Name): THOMAS WAGGONER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2011
Last Update Date: 04/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2605 E CREEKS EDGE DR
BLOOMINGTON IN
47401-8368
US

IV. Provider business mailing address

2605 E CREEKS EDGE DR
BLOOMINGTON IN
47401-8368
US

V. Phone/Fax

Practice location:
  • Phone: 812-135-3334
  • Fax: 812-353-3346
Mailing address:
  • Phone: 812-135-3334
  • Fax: 812-353-3346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05005111A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: