Provider Demographics
NPI:1386698835
Name:WAGGONER, RICHARD K (PA-C)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:K
Last Name:WAGGONER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2116 W FAIDLEY AVE
Mailing Address - Street 2:STE 400
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-4671
Mailing Address - Country:US
Mailing Address - Phone:308-381-0162
Mailing Address - Fax:308-389-4445
Practice Address - Street 1:2116 W FAIDLEY AVE
Practice Address - Street 2:STE 400
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4671
Practice Address - Country:US
Practice Address - Phone:308-381-0162
Practice Address - Fax:308-389-4445
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE342000363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEMW0456726OtherDEA
NE261280Medicare ID - Type Unspecified
NEMW0456726OtherDEA