Provider Demographics
NPI:1881704195
Name:WAGGONER, KATHRYN GIBSON (DO)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:GIBSON
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 MEDICAL PARK LN
Mailing Address - Street 2:SUITE H
Mailing Address - City:MURPHY
Mailing Address - State:NC
Mailing Address - Zip Code:28906-6920
Mailing Address - Country:US
Mailing Address - Phone:828-837-2128
Mailing Address - Fax:828-837-6244
Practice Address - Street 1:125 MEDICAL PARK LN
Practice Address - Street 2:SUITE H
Practice Address - City:MURPHY
Practice Address - State:NC
Practice Address - Zip Code:28906-6920
Practice Address - Country:US
Practice Address - Phone:828-837-2128
Practice Address - Fax:828-837-6244
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9701704208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5904238Medicaid
NC5904238Medicaid