MEDICARE: NICOLE WAGON

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	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1396198891
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE WAGON

Provider Business Mailing Address
First Line	:	PO BOX 190
Second Line	:
City	:	BASIN
State	:	WY
Zip	:	82410-0190
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	#24 GREAT PLAINS RD
Second Line	:
City	:	ARAPAHOE
State	:	WY
Zip	:	82510-0024
Country	:	US
Telephone Number	:	307-856-0470
Fax Number	:

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

Provider Enumeration Date	:	07/20/2016
Last Update Date	:	07/20/2016

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Directions to “ NICOLE WAGON ” Practice Location

Language	Start Address	Practice Location

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