Provider Demographics
NPI:1083059562
Name:BRIANNE C WAGGONER DO PC
Entity Type:Organization
Organization Name:BRIANNE C WAGGONER DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIANNE
Authorized Official - Middle Name:C
Authorized Official - Last Name:WAGGONER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:517-927-9287
Mailing Address - Street 1:9301 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-2767
Mailing Address - Country:US
Mailing Address - Phone:866-321-8433
Mailing Address - Fax:
Practice Address - Street 1:1000 HARRINGTON ST
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-2920
Practice Address - Country:US
Practice Address - Phone:586-493-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-09
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101017372207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty