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1689137408

NPI Code Detail

MEDICARE: DR. JACKSON WAGONER MD

MEDICARE: DR. JACKSON WAGONER MD

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	207LP2900X	Pain Medicine (Anesthesiology) Physician	ME169309	FL
2	207L00000X	Anesthesiology Physician	69349	AZ
3	207LP2900X	Pain Medicine (Anesthesiology) Physician	19414A	WY
4	207L00000X	Anesthesiology Physician	ME169309	FL

General Provider Information

NPI Number	:	1689137408
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACKSON WAGONER MD

Provider Business Mailing Address
First Line	:	PO BOX 100254
Second Line	:
City	:	GAINESVILLE
State	:	FL
Zip	:	32610-0254
Country	:	US
Telephone Number	:	352-273-8610
Fax Number	:	352-273-8612

Provider Business Practice Location Address
First Line	:	1541 DIAMOND DR
Second Line	:
City	:	CASPER
State	:	WY
Zip	:	82601-6247
Country	:	US
Telephone Number	:	307-439-1097
Fax Number	:

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

Provider Enumeration Date	:	04/09/2019
Last Update Date	:	04/08/2026

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Directions to “ DR. JACKSON WAGONER MD” Practice Location

Language	Start Address	Practice Location

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