Organization Name: | WAYNE L. WAGONER, DPM, PC |
NPI Number: | 1568707446 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | WAYNE LEROY WAGONER (OWNER) |
Mailing Address: | 515 Rosemere Ln Maquoketa |
State: | IA US |
Postal Code: | 520602615 |
Phone Number: | 5636529777 |
Fax Number: | 5636529778 |
NPI Enumeration Date: | 12/04/2012 |
NPI Last Update Date: | 12/04/2012 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 261QP1100X |
License Number: | 00526 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | IA |
Taxonomy Type: | Ambulatory Health Care Facilities |
Taxonomy Classification: | Clinic/Center |
Taxonomy Specialization: | Podiatric |
Taxonomy Definition: |