Provider Demographics
NPI:1346913399
Name:WAGOR, CARSON (PA-C)
Entity Type:Individual
Prefix:
First Name:CARSON
Middle Name:
Last Name:WAGOR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 SEAPORT BLVD APT 1515
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02210-3049
Mailing Address - Country:US
Mailing Address - Phone:207-604-0997
Mailing Address - Fax:
Practice Address - Street 1:983 BOSTON-PROVIDENCE TURNPIKE
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026
Practice Address - Country:US
Practice Address - Phone:781-819-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-27
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant