Basic Information
| Provider Information | |||||||||
| NPI: | 1982161659 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNON | ||||||||
| FirstName: | TYLER | ||||||||
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| Credential: | HIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 494 OCKLEY DR | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711052920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188406414 | ||||||||
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| Practice Location | |||||||||
| Address1: | 425 ASHLEY RIDGE BLVD | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711067226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3187973311 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2019 | ||||||||
| LastUpdateDate: | 02/28/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | 1268 | LA | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
No ID Information.