Mary Rose Waggoner, QMHA

Primary specialty

Peer SpecialistTaxonomy code 175T00000X

Practice address

621 W Madrone St
Roseburg, OR 97470-3090

Phone

(541) 440-3532

Fax

(541) 440-3554

NPI assigned

Jul 12, 2012

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Other identifiers 1

Other names 1

• Mary Rose Koerner Other name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1342051200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1644796800000",
    "number": "1083979264",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1121",
            "city": "ROSEBURG",
            "state": "OR",
            "postal_code": "974700254",
            "telephone_number": "541-672-2691"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "621 W MADRONE ST",
            "city": "ROSEBURG",
            "state": "OR",
            "postal_code": "974703090",
            "telephone_number": "541-440-3532",
            "fax_number": "541-440-3554"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WAGGONER",
        "first_name": "MARY",
        "middle_name": "ROSE",
        "credential": "QMHA",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2012-07-12",
        "last_updated": "2022-02-14",
        "certification_date": "2022-02-14",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "171M00000X",
            "taxonomy_group": "",
            "desc": "Case Manager/Care Coordinator",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "172V00000X",
            "taxonomy_group": "",
            "desc": "Community Health Worker",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "175T00000X",
            "taxonomy_group": "",
            "desc": "Peer Specialist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "500663428",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "MARY",
            "last_name": "KOERNER",
            "middle_name": "ROSE",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

• Sarah Vouch, PA-C
• Candice Marie Voynick, LCSW
• Vanessa T Vu, MD
• Kolby Wade, CNM
• Kathleen J Wafer
• Sue Leslie Waite, LCSW
• Wal-Mart Stores, Inc
• Walgreen Co
• Walgreen Co
• Leslie Vernor Walker, MD/MS/ BS/AB

• All providers in Roseburg, OR
• Peer Specialist in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 14, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.