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General NPI Number Information
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NPI Number | 1497797120
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Entity Type | Individual
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Provider Name | JAMES WAGONER LMP
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Gender | Male
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Dates
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Enumeration Date | 06/10/2006
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Last Update Date | 01/16/2009
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Provider Practice Location Address
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Address Line | 1800 COOPER POINT RD SW #21
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City | OLYMPIA
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State | WA
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Zip | 98502-1178
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Country | US
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Telephone | 360-956-1100
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Fax | 360-956-1113
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Provider Business Mailing Address
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Address Line | 5210 CORPORATE CENTER LOOP SE SUITE D
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City | LACEY
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State | WA
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Zip | 98503-5952
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Country | US
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Telephone | 360-455-8155
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Fax | 360-455-1655
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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 | 225700000X
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Taxonomy Name | Massage Therapist
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License Number |
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License Number State |
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