Basic Information
| Provider Information | |||||||||
| NPI: | 1659794451 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGGONER | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | |||||||||
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| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | RODRIGUEZ | ||||||||
| OtherFirstName: | ANGELA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | FNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 16107 KENSINGTON DR STE 126 | ||||||||
| Address2: | |||||||||
| City: | SUGAR LAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774794224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2817838162 | ||||||||
| FaxNumber: | 7134397995 | ||||||||
| Practice Location | |||||||||
| Address1: | 2560 E LEAGUE CITY PKWY | ||||||||
| Address2: | |||||||||
| City: | LEAGUE CITY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775736459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2817838162 | ||||||||
| FaxNumber: | 7134397995 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2014 | ||||||||
| LastUpdateDate: | 04/23/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 848669 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | AP125075 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.