Active NPI
Lucas Jacob Wagoner
- Athletic Trainer
- Columbia, SC
National Provider Identifier
1679244263
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Athletic Trainer
- Practice address
- 1300 Wheat Street
Columbia, SC 29208-0001 - Phone
- (704) 743-6122
- NPI assigned
- Sep 23, 2021
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Student in an Organized Health Care Education/Training Program | 390200000X | |||
| Athletic Trainer | 2255A2300X | Primary |
Addresses
Primary practice location
1300 Wheat Street
Columbia, SC 29208-0001
Mailing address
3932 Rimer Rd
Concord, NC 28025-7375
Phone (704) 743-6122
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1632355200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1684540800000",
"number": "1679244263",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "3932 RIMER RD",
"city": "CONCORD",
"state": "NC",
"postal_code": "280257375",
"telephone_number": "704-743-6122"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1300 WHEAT STREET",
"city": "COLUMBIA",
"state": "SC",
"postal_code": "292080001",
"telephone_number": "704-743-6122"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WAGONER",
"first_name": "LUCAS",
"middle_name": "JACOB",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2021-09-23",
"last_updated": "2023-05-20",
"certification_date": "2023-05-20",
"status": "A"
},
"taxonomies": [
{
"code": "390200000X",
"taxonomy_group": "",
"desc": "Student in an Organized Health Care Education/Training Program",
"state": null,
"license": null,
"primary": false
},
{
"code": "2255A2300X",
"taxonomy_group": "",
"desc": "Specialist/Technologist, Athletic Trainer",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Columbia, SC
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 20, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.