1699854042 NPI number — DR. GEORGE LANE WAGAMAN JR. ED.D.

Table of content: DR. GEORGE LANE WAGAMAN JR. ED.D. (NPI 1699854042)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699854042 NPI number — DR. GEORGE LANE WAGAMAN JR. ED.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAGAMAN
Provider First Name:
GEORGE
Provider Middle Name:
LANE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
ED.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WAGAMAN
Provider Other First Name:
G.
Provider Other Middle Name:
LANE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
ED.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1699854042
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/01/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7332 CAPULIN CREST DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APEX
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27539-4106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-803-6393
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 EUROPA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAPEL HILL
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27517-2357
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-929-1227
Provider Business Practice Location Address Fax Number:
919-968-2575
Provider Enumeration Date:
11/06/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TB0200X , with the licence number:  182 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: 182 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TC0700X , with the licence number: 182 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC1900X , with the licence number: 182 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TF0200X , with the licence number: 182 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TH0100X , with the licence number: 182 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 9205024000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001712519 . This is a "BCBS MTN STATE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".