MEDICARE: KENNETH WADGINSKI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1710I1002X	Independent Duty Corpsman

General Provider Information

NPI Number	:	1285209759
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH WADGINSKI

Provider Business Mailing Address
First Line	:	5-3845 COMBAT MEDIC DRIVE
Second Line	:
City	:	FORT BRAGG
State	:	NC
Zip	:	28310-9610
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5-3845 COMBAT MEDIC DRIVE
Second Line	:
City	:	FORT BRAGG
State	:	NC
Zip	:	28310-9610
Country	:	US
Telephone Number	:	910-394-1059
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/26/2021
Last Update Date	:	05/26/2021

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