Healthcare Provider Details

I. General information

NPI: 1265997191
Provider Name (Legal Business Name): KOURTNEY LENEA WAGGONER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2019
Last Update Date: 02/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2950 ELMWOOD AVE STE A1
KENMORE NY
14217-1304
US

IV. Provider business mailing address

3719 UNION RD STE 218
CHEEKTOWAGA NY
14225-4251
US

V. Phone/Fax

Practice location:
  • Phone: 716-529-3070
  • Fax: 716-529-3071
Mailing address:
  • Phone: 716-206-1503
  • Fax: 716-651-9945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number023195
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: