Basic Information
| Provider Information | |||||||||
| NPI: | 1285686139 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGGONER | ||||||||
| FirstName: | CHAD | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2915 BENJAMIN CT SE | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985014807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607542817 | ||||||||
| FaxNumber: | 3604563894 | ||||||||
| Practice Location | |||||||||
| Address1: | 161 W 200 N STE 200 | ||||||||
| Address2: | |||||||||
| City: | SAINT GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847707386 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356524040 | ||||||||
| FaxNumber: | 4356521516 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 06/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OD00003598 | WA | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.