Provider Demographics
NPI:1265997191
Name:WAGGONER, KOURTNEY LENEA (PA)
Entity type:Individual
Prefix:
First Name:KOURTNEY
Middle Name:LENEA
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3719 UNION RD STE 218
Mailing Address - Street 2:
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225-4251
Mailing Address - Country:US
Mailing Address - Phone:716-206-1503
Mailing Address - Fax:716-651-9945
Practice Address - Street 1:2950 ELMWOOD AVE STE A1
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-1304
Practice Address - Country:US
Practice Address - Phone:716-529-3070
Practice Address - Fax:716-529-3071
Is Sole Proprietor?:No
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY023195363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant