Provider Demographics
NPI:1073909057
Name:WAGNER, ZACHARY (DPT)
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 LONG POND RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-2670
Mailing Address - Country:US
Mailing Address - Phone:774-773-9070
Mailing Address - Fax:508-591-7619
Practice Address - Street 1:65 LONG POND RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-2670
Practice Address - Country:US
Practice Address - Phone:774-773-9070
Practice Address - Fax:508-591-7619
Is Sole Proprietor?:No
Enumeration Date:2015-04-07
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21611225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist