Provider Demographics
NPI:1073151387
Name:WAGNER, NICHOLAS
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:WAGNER
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 1:358 LAGOON LANE
Mailing Address - Street 2:
Mailing Address - City:SILVERTHORNE
Mailing Address - State:CO
Mailing Address - Zip Code:80498
Mailing Address - Country:US
Mailing Address - Phone:218-443-3560
Mailing Address - Fax:
Practice Address - Street 1:358 LAGOON LANE
Practice Address - Street 2:
Practice Address - City:SILVERTHORNE
Practice Address - State:CO
Practice Address - Zip Code:80498
Practice Address - Country:US
Practice Address - Phone:218-443-3560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-17
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR346355224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant