Provider Demographics
NPI:1871200766
Name:WAGONER, MADDIE A (ATS)
Entity type:Individual
Prefix:
First Name:MADDIE
Middle Name:A
Last Name:WAGONER
Suffix:
Gender:F
Credentials:ATS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 E HALLIDAY ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4824
Mailing Address - Country:US
Mailing Address - Phone:208-851-8361
Mailing Address - Fax:
Practice Address - Street 1:1040 GULF BREEZE PKWY STE 203
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-7808
Practice Address - Country:US
Practice Address - Phone:208-851-8361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-01
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FL70192255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program