=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336727163
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREW JACOB WAGONER RRT-NPS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2021
-----------------------------------------------------
Last Update Date | 09/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 E VETERANS ST
-----------------------------------------------------
City | TOMAH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54660-3105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-372-3971
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 E VETERANS ST
-----------------------------------------------------
City | TOMAH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54660-3105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-372-3971
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174H00000X
-----------------------------------------------------
Taxonomy Name | Health Educator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2279P3900X
-----------------------------------------------------
Taxonomy Name | Neonatal/Pediatric Registered Respiratory Therapist
-----------------------------------------------------
License Number | 122206
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 227900000X
-----------------------------------------------------
Taxonomy Name | Registered Respiratory Therapist
-----------------------------------------------------
License Number | 122206
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------