Basic Information
| Provider Information | |||||||||
| NPI: | 1003834169 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGGENSPACK | ||||||||
| FirstName: | WAME | ||||||||
| MiddleName: | NICHOLAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8080 BLUEBONNET BLVD | ||||||||
| Address2: | SUITE 1000 | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708107827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2259242424 | ||||||||
| FaxNumber: | 2254087984 | ||||||||
| Practice Location | |||||||||
| Address1: | 8080 BLUEBONNET BLVD | ||||||||
| Address2: | SUITE 1000 | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708107827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2259242424 | ||||||||
| FaxNumber: | 2254087984 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 04/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 19439 | MS | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 201531 | LA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207QS0010X | 19439 | MS | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207QS0010X | 201531 | LA | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207X00000X | 201531 | LA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 04476300 | 05 | MS | MEDICAID | 1018236 | 05 | LA | MEDICAID |