NPI Code Detail JSON Logo

1053290197 NPI number — MACKENZIE MARIE WAGAMAN

NPI Number: 1053290197
Health Care Provider/Practitioner: MACKENZIE MARIE WAGAMAN

Information about “1053290197” NPI (MACKENZIE MARIE WAGAMAN) exists in 1053290197 in HTML format HTML  |  1053290197 in plain Text format TXT  |  1053290197 in PDF (Portable Document Format) PDF  |  1053290197 in an XML format XML  formats.

NPI Number : 1053290197 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1053290197",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "N",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "WAGAMAN",
    "FirstName": "MACKENZIE",
    "MiddleName": "MARIE",
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": null,
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": "FRITZ",
    "OtherFirstName": "MACKENZIE",
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": "1",
    "FirstLineMailingAddress": "208 4TH ST SW",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "KASSON",
    "MailingAddressStateName": "MN",
    "MailingAddressPostalCode": "55944-1244",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "320-309-2620",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "5067 55TH ST NW",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "ROCHESTER",
    "PracticeLocationAddressStateName": "MN",
    "PracticeLocationAddressPostalCode": "55901-3809",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "507-292-7070",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "09/02/2025",
    "LastUpdateDate": "09/02/2025",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "F",
    "Gender": "Female",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "390200000X",
        "TaxonomyName": "Student in an Organized Health Care Education/Training Program",
        "LicenseNumber": null,
        "LicenseNumberStateCode": "MN",
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

Copyright © 2007-2026 Data Labs Health. All rights reserved.