1083059562 NPI number — BRIANNE C WAGGONER DO PC

Table of content: (NPI 1083059562)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083059562 NPI number — BRIANNE C WAGGONER DO PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIANNE C WAGGONER DO PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083059562
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/09/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9301 S WESTERN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73139-2767
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-321-8433
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 HARRINGTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT CLEMENS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48043-2920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-493-8000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/09/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WAGGONER
Authorized Official First Name:
BRIANNE
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
517-927-9287

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  5101017372 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)