Provider Demographics
NPI:1245769538
Name:WAGNER, ERIN L (PTA, LMT)
Entity Type:Individual
Prefix:MRS
First Name:ERIN
Middle Name:L
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PTA, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25-3420 PAKELEKIA ST
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-1318
Mailing Address - Country:US
Mailing Address - Phone:808-987-1879
Mailing Address - Fax:
Practice Address - Street 1:69 RAILROAD AVE STE A4
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-7509
Practice Address - Country:US
Practice Address - Phone:808-339-7861
Practice Address - Fax:808-339-7989
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT-14701225700000X
HIPTA-192225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist