MEDICARE: DR. MATTHEW ROY WAGONER DPM

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	213ES0103X	Foot & Ankle Surgery Podiatrist	SC006317	PA
2	213ES0103X	Foot & Ankle Surgery Podiatrist	612	NC

General Provider Information

NPI Number	:	1770870974
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MATTHEW ROY WAGONER DPM

Provider Business Mailing Address
First Line	:	2001 N CHURCH ST
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27405-5633
Country	:	US
Telephone Number	:	336-375-6990
Fax Number	:	336-375-0361

Provider Business Practice Location Address
First Line	:	2001 N CHURCH ST STE 101
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27405-5633
Country	:	US
Telephone Number	:	336-375-6990
Fax Number	:

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

Provider Enumeration Date	:	07/08/2011
Last Update Date	:	03/11/2024

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