Provider Demographics
NPI:1508308719
Name:WAGAMAN, CARA
Entity Type:Individual
Prefix:
First Name:CARA
Middle Name:
Last Name:WAGAMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 E DIAMOND AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-5321
Mailing Address - Country:US
Mailing Address - Phone:301-330-4359
Mailing Address - Fax:
Practice Address - Street 1:610 E DIAMOND AVE
Practice Address - Street 2:SUITE E
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-5321
Practice Address - Country:US
Practice Address - Phone:301-330-4359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-07
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD5299171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator