Provider Demographics
NPI:1639645245
Name:WAGGONER, CAMERON (PT, DPT, NCS)
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:
Last Name:WAGGONER
Suffix:
Gender:M
Credentials:PT, DPT, NCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 25451
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22313-5451
Mailing Address - Country:US
Mailing Address - Phone:901-288-8063
Mailing Address - Fax:
Practice Address - Street 1:400 MADISON ST APT 1406
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-1724
Practice Address - Country:US
Practice Address - Phone:901-288-8062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-22
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305212507225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist