Provider Demographics
NPI:1134298961
Name:WAGERS, LISA JEAN (PT)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:JEAN
Last Name:WAGERS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 TAYLOR RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47203-3102
Mailing Address - Country:US
Mailing Address - Phone:812-314-2378
Mailing Address - Fax:812-373-7616
Practice Address - Street 1:2505 TAYLOR RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47203-3102
Practice Address - Country:US
Practice Address - Phone:812-314-2378
Practice Address - Fax:812-373-7616
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05004643A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist