Individual
MADDIE A WAGONER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
ATS
Contact information
Practice address
1040 GULF BREEZE PKWY STE 203, GULF BREEZE, FL 32561-7808
(208) 851-8361
Mailing address
1110 E HALLIDAY ST, POCATELLO, ID 83201-4824
(208) 851-8361
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
7019
FL
390200000X
Student in an Organized Health Care Education/Training Program
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Other
Enumeration date
11/01/2022
Last updated
07/10/2024
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