Provider Demographics
NPI:1306401567
Name:WAGNER, RONALD W (PT, DPT)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:W
Last Name:WAGNER
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6397 LEE HWY STE 300
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-4915
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:415 S 10TH ST
Practice Address - Street 2:
Practice Address - City:ATCHISON
Practice Address - State:KS
Practice Address - Zip Code:66002-2771
Practice Address - Country:US
Practice Address - Phone:913-370-9500
Practice Address - Fax:913-367-5061
Is Sole Proprietor?:No
Enumeration Date:2019-05-03
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-03052225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist