Healthcare Provider Details

I. General information

NPI: 1508043597
Provider Name (Legal Business Name): PERRY M. WAGGONER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2008
Last Update Date: 01/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 SIERRA ROSE DR SUITE B
RENO NV
89511-2072
US

IV. Provider business mailing address

650 SIERRA ROSE DR SUITE B
RENO NV
89511-2072
US

V. Phone/Fax

Practice location:
  • Phone: 775-322-3311
  • Fax: 775-322-8388
Mailing address:
  • Phone: 775-322-3311
  • Fax: 775-322-8388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD7268
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberMD7268
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: