Provider Demographics
NPI:1477634582
Name:WAGGONER, AMANDA MITCHELL (PAC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MITCHELL
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:B
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6160 KEMPSVILLE CIR
Mailing Address - Street 2:SUITE 200 A
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-3933
Mailing Address - Country:US
Mailing Address - Phone:757-622-6315
Mailing Address - Fax:757-625-6940
Practice Address - Street 1:6160 KEMPSVILLE CIR
Practice Address - Street 2:SUITE 200 A
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-3933
Practice Address - Country:US
Practice Address - Phone:757-622-6315
Practice Address - Fax:757-625-6940
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002368363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA012469P05OtherMEDICARE PTAN
VA0110002368OtherVA BRD OF MEDICINE LIC #
VA0110002368OtherVA BRD OF MEDICINE LIC #