Provider Demographics
NPI:1639266968
Name:WAGGONER, WENDE (OD, MPH, MS)
Entity Type:Individual
Prefix:DR
First Name:WENDE
Middle Name:
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:OD, MPH, MS
Other - Prefix:DR
Other - First Name:WENDE
Other - Middle Name:WAGGONER
Other - Last Name:WU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD, MPH, MS
Mailing Address - Street 1:135 W 27TH ST
Mailing Address - Street 2:FL 4
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-6226
Mailing Address - Country:US
Mailing Address - Phone:212-257-0007
Mailing Address - Fax:646-219-5737
Practice Address - Street 1:500 EUBANK BLVD SE
Practice Address - Street 2:STE A
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87123-3338
Practice Address - Country:US
Practice Address - Phone:505-323-2555
Practice Address - Fax:505-323-0888
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2017-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM547152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U92191Medicare UPIN