Provider Demographics
NPI:1043413859
Name:WAGNER, MATTHEW (PT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 CEDARWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80504-8785
Mailing Address - Country:US
Mailing Address - Phone:207-831-6697
Mailing Address - Fax:
Practice Address - Street 1:2150 STADIUM DRIVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80309-1361
Practice Address - Country:US
Practice Address - Phone:303-315-9900
Practice Address - Fax:303-315-9902
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029375225100000X
COPTL.0010633225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ99558Medicare PIN