Provider Demographics
NPI:1225911472
Name:WAGGONER, BRETT (LAC)
Entity type:Individual
Prefix:MR
First Name:BRETT
Middle Name:
Last Name:WAGGONER
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10249 SW 101ST AVE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-6094
Mailing Address - Country:US
Mailing Address - Phone:561-281-2143
Mailing Address - Fax:
Practice Address - Street 1:303 SW 140TH TER
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:FL
Practice Address - Zip Code:32669-3042
Practice Address - Country:US
Practice Address - Phone:561-281-2143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-28
Last Update Date:2025-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP4586171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist