Active NPI
Maddie A Wagoner, ATS
- Athletic Trainer
- Gulf Breeze, FL
National Provider Identifier
1871200766
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Athletic Trainer
- License
- 7019
- Practice address
- 1040 Gulf Breeze Pkwy Ste 203
Gulf Breeze, FL 32561-7808 - Phone
- (208) 851-8361
- NPI assigned
- Nov 1, 2022
- Last updated
- Jul 10, 2024
- Sex
- Female
- 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 | NU | ||
| Athletic Trainer | 2255A2300X | 7019 | FL | Primary |
Addresses
Primary practice location
1040 Gulf Breeze Pkwy Ste 203
Gulf Breeze, FL 32561-7808
Mailing address
1110 E Halliday St
Pocatello, ID 83201-4824
Phone (208) 851-8361
Electronic endpoints 1
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| Other URL | N/A |
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
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 7019 | FL | MD | Athletic Trainer |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1667260800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1720569600000",
"number": "1871200766",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1110 E HALLIDAY ST",
"city": "POCATELLO",
"state": "ID",
"postal_code": "832014824",
"telephone_number": "208-851-8361"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1040 GULF BREEZE PKWY STE 203",
"city": "GULF BREEZE",
"state": "FL",
"postal_code": "325617808",
"telephone_number": "208-851-8361"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WAGONER",
"first_name": "MADDIE",
"middle_name": "A",
"credential": "ATS",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2022-11-01",
"last_updated": "2024-07-10",
"certification_date": "2024-07-10",
"status": "A"
},
"taxonomies": [
{
"code": "390200000X",
"taxonomy_group": "",
"desc": "Student in an Organized Health Care Education/Training Program",
"state": "NU",
"license": null,
"primary": false
},
{
"code": "2255A2300X",
"taxonomy_group": "",
"desc": "Specialist/Technologist, Athletic Trainer",
"state": "FL",
"license": "7019",
"primary": true
}
],
"identifiers": [],
"endpoints": [
{
"endpointType": "OTHERS",
"endpointTypeDescription": "Other URL",
"endpoint": "N/A",
"affiliation": "N",
"address_1": "1110 E Halliday St",
"city": "Pocatello",
"state": "ID",
"country_code": "US",
"postal_code": "832014824",
"country_name": "United States",
"address_type": "DOM"
}
],
"other_names": []
}Other providers in Gulf Breeze, FL
- Danielle Vinson, LCSW
- Stephen Vinson, EDD, LCSW-QS
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- Lynda Kay Voronin
- Brid M Wade, APRN
- Wal-Mart Stores East LP (WalMart Pharmacy 10-5623)
- Wal-Mart Stores East LP (Walmart Pharmacy 10-2533)
- Wal-Mart Stores East, LP (Vision Center 30-2533)
- Tracy Walck, OT
- Walgreen Co (Walgreens #06210)
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 10, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.