Provider Demographics
NPI:1003834169
Name:WAGGENSPACK, WAME NICHOLAS JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WAME
Middle Name:NICHOLAS
Last Name:WAGGENSPACK
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8080 BLUEBONNET BLVD
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-7827
Mailing Address - Country:US
Mailing Address - Phone:225-924-2424
Mailing Address - Fax:225-408-7984
Practice Address - Street 1:8080 BLUEBONNET BLVD
Practice Address - Street 2:SUITE 1000
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-7827
Practice Address - Country:US
Practice Address - Phone:225-924-2424
Practice Address - Fax:225-408-7984
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS19439207P00000X, 207QS0010X
LA201531207P00000X, 207QS0010X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04476300Medicaid
LA1018236Medicaid
LA1018236Medicaid
MS930003713Medicare ID - Type Unspecified
MS04476300Medicaid
LA4K999Medicare PIN