Provider Demographics
NPI:1083066112
Name:WAGNER, AUSTIN MICHAEL (ATC)
Entity Type:Individual
Prefix:MR
First Name:AUSTIN
Middle Name:MICHAEL
Last Name:WAGNER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 STILLBROOK ESTATES DR
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-6505
Mailing Address - Country:US
Mailing Address - Phone:314-960-1037
Mailing Address - Fax:
Practice Address - Street 1:6300 JAMES S MCDONNELL BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63134-1940
Practice Address - Country:US
Practice Address - Phone:314-232-8702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-13
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20180091472255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2018009147OtherATHLETIC TRAINER