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General NPI Number Information
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NPI Number | 1639645245
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Entity Type | Individual
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Provider Name | CAMERON WAGGONER PT, DPT, NCS
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Gender | Male
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Dates
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Enumeration Date | 10/22/2018
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Last Update Date | 06/17/2024
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Provider Practice Location Address
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Address Line | 400 MADISON ST APT 1406
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City | ALEXANDRIA
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State | VA
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Zip | 22314-1724
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Country | US
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Telephone | 901-288-8062
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 25451
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City | ALEXANDRIA
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State | VA
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Zip | 22313-5451
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Country | US
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Telephone | 901-288-8063
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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 | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 2305212507
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License Number State | VA
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