Provider Demographics
NPI:1336727163
Name:WAGONER, ANDREW JACOB (RRT-NPS)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:JACOB
Last Name:WAGONER
Suffix:
Gender:M
Credentials:RRT-NPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E VETERANS ST
Mailing Address - Street 2:
Mailing Address - City:TOMAH
Mailing Address - State:WI
Mailing Address - Zip Code:54660-3105
Mailing Address - Country:US
Mailing Address - Phone:608-372-3971
Mailing Address - Fax:
Practice Address - Street 1:500 E VETERANS ST
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660-3105
Practice Address - Country:US
Practice Address - Phone:608-372-3971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-01
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI174H00000X
WI1222062279P3900X, 227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered
No174H00000XOther Service ProvidersHealth Educator
No2279P3900XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredNeonatal/Pediatrics