Provider Demographics
NPI:1467958942
Name:WAGGONER, CORAL JANE (RPSGT, RRT,CCSH,MBA)
Entity Type:Individual
Prefix:
First Name:CORAL
Middle Name:JANE
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:RPSGT, RRT,CCSH,MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1869 MONTARA CT NW
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-8384
Mailing Address - Country:US
Mailing Address - Phone:505-872-6005
Mailing Address - Fax:505-872-6003
Practice Address - Street 1:4700 JEFFERSON ST NE STE 800
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-2132
Practice Address - Country:US
Practice Address - Phone:505-872-6005
Practice Address - Fax:515-872-6003
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPT2013-0001246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherGroup - Single Specialty