Provider Demographics
NPI:1205018710
Name:WAGGONER, PHILLIP RAY (PT)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:RAY
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 1:5915 PONCE DE LEON BLVD
Mailing Address - Street 2:PLUMER BLDG.,5TH FLOOR
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-2435
Mailing Address - Country:US
Mailing Address - Phone:305-284-4535
Mailing Address - Fax:305-284-6128
Practice Address - Street 1:5915 PONCE DE LEON BLVD
Practice Address - Street 2:PLUMER BLDG.,5TH FLOOR
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-2435
Practice Address - Country:US
Practice Address - Phone:305-284-4535
Practice Address - Fax:305-284-6128
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 7485225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist