Provider Demographics
NPI:1780430207
Name:STILLWAGON, ANDREW (MS, RDN, LDN)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:STILLWAGON
Suffix:
Gender:M
Credentials:MS, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3103 SHANNON RD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-4336
Mailing Address - Country:US
Mailing Address - Phone:919-865-3869
Mailing Address - Fax:
Practice Address - Street 1:3103 SHANNON RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-4336
Practice Address - Country:US
Practice Address - Phone:919-865-3869
Practice Address - Fax:866-284-2848
Is Sole Proprietor?:No
Enumeration Date:2024-04-25
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL006974133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered