Provider Demographics
NPI:1346815933
Name:WAGGONER, ASHLEY (DPT)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2910 BLUFF ST APT 111
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-1266
Mailing Address - Country:US
Mailing Address - Phone:267-474-5337
Mailing Address - Fax:
Practice Address - Street 1:315 W SOUTH BOULDER RD # 100AND
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:CO
Practice Address - Zip Code:80027-1156
Practice Address - Country:US
Practice Address - Phone:303-666-4151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0017640225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist