Provider Demographics
NPI:1679244263
Name:WAGONER, LUCAS JACOB
Entity type:Individual
Prefix:
First Name:LUCAS
Middle Name:JACOB
Last Name:WAGONER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3932 RIMER RD
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-7375
Mailing Address - Country:US
Mailing Address - Phone:704-743-6122
Mailing Address - Fax:
Practice Address - Street 1:1300 WHEAT STREET
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29208-0001
Practice Address - Country:US
Practice Address - Phone:704-743-6122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-23
Last Update Date:2023-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program