Provider Demographics
NPI:1689011405
Name:WAGAMAN, NICOLE ANN (DO)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANN
Last Name:WAGAMAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:129 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-4949
Practice Address - Country:US
Practice Address - Phone:803-774-9680
Practice Address - Fax:803-434-3955
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI67461208100000X
IADO-055462081P0004X
LA3312232081P0004X
SC87896208100000X
IAR-9752207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P0004XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSpinal Cord Injury Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine