Provider Demographics
NPI:1356820294
Name:STAGGERS, IAN
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:STAGGERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8978 WATCHLIGHT CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-4223
Mailing Address - Country:US
Mailing Address - Phone:301-741-8075
Mailing Address - Fax:
Practice Address - Street 1:3501 HAMILTON ST STE 205-B
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20782-3961
Practice Address - Country:US
Practice Address - Phone:301-741-8075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-10
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM04425225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist