Provider Demographics
NPI:1225103476
Name:WAGNER, RICHARD D JR (PT CSCS VCS)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:D
Last Name:WAGNER
Suffix:JR
Gender:M
Credentials:PT CSCS VCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 MALIBU DR
Mailing Address - Street 2:
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012-9713
Mailing Address - Country:US
Mailing Address - Phone:262-618-4787
Mailing Address - Fax:262-375-4975
Practice Address - Street 1:2020 CHEYENNE CT
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WI
Practice Address - Zip Code:53024-0368
Practice Address - Country:US
Practice Address - Phone:262-375-1075
Practice Address - Fax:262-375-4975
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5865024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40408000Medicaid