Provider Demographics
NPI:1750538310
Name:WAGGONER, SKYE GUSTIN (PA-C)
Entity type:Individual
Prefix:MS
First Name:SKYE
Middle Name:GUSTIN
Last Name:WAGGONER
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Gender:F
Credentials:PA-C
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Mailing Address - Street 1:3896 BEVERLY AVE NE
Mailing Address - Street 2:BLDG J, STE 40
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-1374
Mailing Address - Country:US
Mailing Address - Phone:503-588-0076
Mailing Address - Fax:
Practice Address - Street 1:3896 BEVERLY AVE NE
Practice Address - Street 2:BLDG J, STE 40
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1374
Practice Address - Country:US
Practice Address - Phone:503-588-0076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-25
Last Update Date:2008-08-25
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant