Provider Demographics
NPI:1730460635
Name:WAIGWA, STEPHEN KAGONDU (PTA)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:KAGONDU
Last Name:WAIGWA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7401 PHOENIX AVE
Mailing Address - Street 2:APT 46
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79915-1932
Mailing Address - Country:US
Mailing Address - Phone:915-227-1719
Mailing Address - Fax:
Practice Address - Street 1:1755 CURIE DR
Practice Address - Street 2:# A
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-2919
Practice Address - Country:US
Practice Address - Phone:915-544-3636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2082367225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant