Healthcare Provider Details

I. General information

NPI: 1316091275
Provider Name (Legal Business Name): MICHELLE K WAGGONER DC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 02/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 NE HOOD AVE, STE 205
GRESHAM OR
97030
US

IV. Provider business mailing address

501 NE HOOD AVE, STE 205
GRESHAM OR
97030
US

V. Phone/Fax

Practice location:
  • Phone: 503-674-7894
  • Fax: 503-674-7899
Mailing address:
  • Phone: 503-674-7894
  • Fax: 503-674-7899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number71 3666
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: