Provider Demographics
NPI:1194079657
Name:WAGONER, RODGER KEITH (PA-C)
Entity type:Individual
Prefix:MR
First Name:RODGER
Middle Name:KEITH
Last Name:WAGONER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 70969
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31708-0969
Mailing Address - Country:US
Mailing Address - Phone:229-435-1458
Mailing Address - Fax:229-317-2342
Practice Address - Street 1:2405 OSLER CT
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-0214
Practice Address - Country:US
Practice Address - Phone:229-435-1458
Practice Address - Fax:229-317-2342
Is Sole Proprietor?:No
Enumeration Date:2012-11-06
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA006662363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant