Provider Demographics
NPI:1770870974
Name:WAGONER, MATTHEW ROY (DPM)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:ROY
Last Name:WAGONER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-5633
Mailing Address - Country:US
Mailing Address - Phone:336-375-6990
Mailing Address - Fax:336-375-0361
Practice Address - Street 1:2001 N CHURCH ST STE 101
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-5633
Practice Address - Country:US
Practice Address - Phone:336-375-6990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-08
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC006317213ES0103X
NC612213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery