Provider Demographics
NPI:1518953660
Name:WAGGONER, ROBIN M (PA-C)
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:M
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56-565 KAMEHAMEHA HWY
Mailing Address - Street 2:
Mailing Address - City:KAHUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96731-2202
Mailing Address - Country:US
Mailing Address - Phone:808-432-3900
Mailing Address - Fax:
Practice Address - Street 1:56-565 KAMEHAMEHA HWY
Practice Address - Street 2:
Practice Address - City:KAHUKU
Practice Address - State:HI
Practice Address - Zip Code:96731-2202
Practice Address - Country:US
Practice Address - Phone:808-432-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15343363AM0700X
HIAMD-634363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ24807Medicare UPIN
CAWPA15343AMedicare ID - Type Unspecified