Healthcare Provider Details

I. General information

NPI: 1689137408
Provider Name (Legal Business Name): JACKSON WAGONER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1541 DIAMOND DR
CASPER WY
82601-6247
US

IV. Provider business mailing address

PO BOX 100254
GAINESVILLE FL
32610-0254
US

V. Phone/Fax

Practice location:
  • Phone: 307-439-1097
  • Fax:
Mailing address:
  • Phone: 352-273-8610
  • Fax: 352-273-8612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberME169309
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number69349
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number19414A
License Number StateWY
# 4
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberME169309
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: