Provider Demographics
NPI:1538249727
Name:WAGGONER, MATTHEW R (PT)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:R
Last Name:WAGGONER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6860 NW 73RD ST
Mailing Address - Street 2:
Mailing Address - City:PARKLAND
Mailing Address - State:FL
Mailing Address - Zip Code:33067-3916
Mailing Address - Country:US
Mailing Address - Phone:561-955-9384
Mailing Address - Fax:561-392-7395
Practice Address - Street 1:22791 VIA DE SONRISA DEL NORTE
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433
Practice Address - Country:US
Practice Address - Phone:561-955-9384
Practice Address - Fax:561-392-7395
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT18303225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist