Provider Demographics
NPI:1174827190
Name:WAGGONER, KRISTEN J (PA)
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:J
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:PA
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Other - First Name:
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Mailing Address - Street 1:4944 SUNRISE BLVD
Mailing Address - Street 2:SUITE H
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-4941
Mailing Address - Country:US
Mailing Address - Phone:916-966-8158
Mailing Address - Fax:916-966-8118
Practice Address - Street 1:4944 SUNRISE BLVD STE H
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-4941
Practice Address - Country:US
Practice Address - Phone:916-966-8158
Practice Address - Fax:916-966-8118
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-05
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA20275363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant