Individual
KENNETH GABRIEL WAGONER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PTA
Contact information
Practice address
1845 E BROAD ST, STATESVILLE, NC 28625-4307
(980) 890-3255
Mailing address
184 REDEMPTION RD, STATESVILLE, NC 28625-1526
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
A8675
NC
Other
Enumeration date
09/16/2025
Last updated
09/16/2025
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