Healthcare Provider Details

I. General information

NPI: 1295645505
Provider Name (Legal Business Name): WILLARD COLE WAGGONER PT, DPT, CSCS
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7311 GROVE RD STE H
FREDERICK MD
21704-3300
US

IV. Provider business mailing address

6700B OVERTON CIR APT 21
FREDERICK MD
21703-7047
US

V. Phone/Fax

Practice location:
  • Phone: 240-608-6031
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number30981
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: