Provider Demographics
NPI:1316562150
Name:WAGNER, PATRICK (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:
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 1:8751 W CHARLESTON BLVD STE 270
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-5497
Mailing Address - Country:US
Mailing Address - Phone:702-982-2232
Mailing Address - Fax:
Practice Address - Street 1:8751 W CHARLESTON BLVD STE 270
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-5497
Practice Address - Country:US
Practice Address - Phone:702-982-2232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-08
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4291225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV4291OtherSTATE LICENSE