Healthcare Provider Details

I. General information

NPI: 1003834169
Provider Name (Legal Business Name): WAME NICHOLAS WAGGENSPACK JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 02/26/2025
Certification Date: 02/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8080 BLUEBONNET BLVD SUITE 1000
BATON ROUGE LA
70810-7827
US

IV. Provider business mailing address

8080 BLUEBONNET BLVD SUITE 1000
BATON ROUGE LA
70810-7827
US

V. Phone/Fax

Practice location:
  • Phone: 225-924-2424
  • Fax: 225-408-7984
Mailing address:
  • Phone: 225-924-2424
  • Fax: 225-408-7984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number201531
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number19439
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number19439
License Number StateMS
# 4
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number201531
License Number StateLA
# 5
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberL9952
License Number StateTX
# 6
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number201531
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: