Provider Demographics
NPI:1083483713
Name:WAGGONER, AMBER LEIA (NP)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:LEIA
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2413 MEMORIAL PKWY
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78374-3209
Mailing Address - Country:US
Mailing Address - Phone:361-643-4546
Mailing Address - Fax:361-758-2137
Practice Address - Street 1:2413 MEMORIAL PKWY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TX
Practice Address - Zip Code:78374-3209
Practice Address - Country:US
Practice Address - Phone:361-643-4546
Practice Address - Fax:361-758-2137
Is Sole Proprietor?:No
Enumeration Date:2023-12-21
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1145675363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily