Provider Demographics
NPI:1609503507
Name:WAGAMAN, AMANDA CORILYN
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:CORILYN
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 1:26812 118TH AVE. E.
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98338
Mailing Address - Country:US
Mailing Address - Phone:844-623-9675
Mailing Address - Fax:
Practice Address - Street 1:1992 RIDGEVIEW LOOP SW APT 206
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-1455
Practice Address - Country:US
Practice Address - Phone:360-584-2344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program