Provider Demographics
NPI:1043895261
Name:WAGGONER, STEPHEN JAMES (PT)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:JAMES
Last Name:WAGGONER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 601791
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1791
Mailing Address - Country:US
Mailing Address - Phone:336-718-6931
Mailing Address - Fax:336-718-3389
Practice Address - Street 1:190 KIMEL PARK DR STE 139
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6946
Practice Address - Country:US
Practice Address - Phone:336-718-6931
Practice Address - Fax:336-718-3389
Is Sole Proprietor?:No
Enumeration Date:2021-03-10
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP15783225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist