Provider Demographics
NPI:1891521498
Name:WAGGONER, SARA
Entity type:Individual
Prefix:
First Name:SARA
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 1:2725 LINCOLN ST E
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44707-2769
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2725 LINCOLN ST E
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44707-2769
Practice Address - Country:US
Practice Address - Phone:330-454-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-10
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.454092163W00000X
OHAPRN.CNP.0037701363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse