Provider Demographics
NPI:1144765652
Name:WAGNER, SARA (PTA)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 S CLARK ST
Mailing Address - Street 2:
Mailing Address - City:MAYVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53050-1488
Mailing Address - Country:US
Mailing Address - Phone:920-387-1372
Mailing Address - Fax:920-387-1370
Practice Address - Street 1:305 S CLARK ST
Practice Address - Street 2:
Practice Address - City:MAYVILLE
Practice Address - State:WI
Practice Address - Zip Code:53050-1488
Practice Address - Country:US
Practice Address - Phone:920-387-1372
Practice Address - Fax:920-387-1370
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2439-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant