Provider Demographics
NPI:1508043597
Name:WAGGONER, PERRY M (MD)
Entity Type:Individual
Prefix:
First Name:PERRY
Middle Name:M
Last Name:WAGGONER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 SIERRA ROSE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-2072
Mailing Address - Country:US
Mailing Address - Phone:775-322-3311
Mailing Address - Fax:775-322-8388
Practice Address - Street 1:650 SIERRA ROSE DR
Practice Address - Street 2:SUITE B
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-2072
Practice Address - Country:US
Practice Address - Phone:775-322-3311
Practice Address - Fax:775-322-8388
Is Sole Proprietor?:No
Enumeration Date:2008-01-22
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVMD7268207W00000X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
F58998Medicare UPIN
V34495Medicare PIN