Provider Demographics
NPI:1013044197
Name:WAGNER, JOHN DANIEL (LMP)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DANIEL
Last Name:WAGNER
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2315 N PEARL ST STE 10
Mailing Address - Street 2:PMB 188
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98406-2553
Mailing Address - Country:US
Mailing Address - Phone:253-905-0533
Mailing Address - Fax:253-752-1122
Practice Address - Street 1:2315 N PEARL ST STE 10
Practice Address - Street 2:PMB 188
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406-2553
Practice Address - Country:US
Practice Address - Phone:253-905-0533
Practice Address - Fax:253-752-1122
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA16406225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist