Individual
LUCAS JACOB WAGONER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
1300 WHEAT STREET, COLUMBIA, SC 29208-0001
(704) 743-6122
Mailing address
3932 RIMER RD, CONCORD, NC 28025-7375
(704) 743-6122
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
—
—
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
09/23/2021
Last updated
05/20/2023
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