Individual
SAMUEL RUSSELL WAGGONER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
2727 NE FLANDERS ST, PORTLAND, OR 97232-3159
(503) 238-5203
Mailing address
2901 E BURNSIDE ST, PORTLAND, OR 97214-1831
(503) 238-5203
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
T-22-1492
OR
Other
Enumeration date
12/05/2022
Last updated
12/05/2022
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