Provider Demographics
NPI:1326062423
Name:WAGHORN, STEVE P (PT,MS)
Entity Type:Individual
Prefix:
First Name:STEVE
Middle Name:P
Last Name:WAGHORN
Suffix:
Gender:M
Credentials:PT,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 HIGHWAY 314 SW
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-9600
Mailing Address - Country:US
Mailing Address - Phone:505-866-0055
Mailing Address - Fax:
Practice Address - Street 1:535 HIGHWAY 314 SW
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-9600
Practice Address - Country:US
Practice Address - Phone:505-866-0055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3129225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000Q0406OtherMEDICAID GROUP #
NM3129OtherNM STATE LICENSE
NM33607851Medicaid
NM1245380039OtherBERNALILLO FACILITY NPI
NM1356491146OtherBELEN FACILITY NPI
NM1386651412OtherLOS LUNAS FACILITY NPI
NMP00253827OtherRAILROAD MEDICARE
NMP00253827OtherRAILROAD MEDICARE
NM343511901Medicare PIN