Provider Demographics
NPI:1316344377
Name:WAGGONER, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1672 TANK RD
Mailing Address - Street 2:
Mailing Address - City:ODUM
Mailing Address - State:GA
Mailing Address - Zip Code:31555-7108
Mailing Address - Country:US
Mailing Address - Phone:912-424-0513
Mailing Address - Fax:
Practice Address - Street 1:1672 TANK RD
Practice Address - Street 2:
Practice Address - City:ODUM
Practice Address - State:GA
Practice Address - Zip Code:31555-7108
Practice Address - Country:US
Practice Address - Phone:912-424-0513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-19
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2654632471M2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471M2300XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMammography