Healthcare Provider Details

I. General information

NPI: 1548242514
Provider Name (Legal Business Name): RICHARD ADAM WAGGONER PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 08/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGAR MAPLE DR
WPAFB OH
45433-5546
US

IV. Provider business mailing address

4881 SUGAR MAPLE DR
WPAFB OH
45433-5546
US

V. Phone/Fax

Practice location:
  • Phone: 937-257-0770
  • Fax:
Mailing address:
  • Phone: 937-257-0770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: