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General NPI Number Information
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NPI Number | 1225653967
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Entity Type | Individual
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Provider Name | MOLLY ANN WAGGONER PA-C
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Gender | Female
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Dates
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Enumeration Date | 06/09/2020
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Last Update Date | 06/09/2020
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Provider Practice Location Address
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Address Line | 9050 EXECUTIVE PARK DR STE 100B
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City | KNOXVILLE
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State | TN
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Zip | 37923-4616
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Country | US
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Telephone | 865-217-1297
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Fax |
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Provider Business Mailing Address
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Address Line | 379 MIKE MILLER LN
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City | CLINTON
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State | TN
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Zip | 37716-6545
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Country | US
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Telephone | 865-660-8236
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 4115
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License Number State | TN
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