Provider Demographics
NPI:1376222638
Name:WAGNER, DEBRA (PTA)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:
Other - Last Name:HULSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:92102 W GOOD RD
Mailing Address - Street 2:
Mailing Address - City:PROSSER
Mailing Address - State:WA
Mailing Address - Zip Code:99350-5653
Mailing Address - Country:US
Mailing Address - Phone:509-781-2196
Mailing Address - Fax:
Practice Address - Street 1:92102 W GOOD RD
Practice Address - Street 2:
Practice Address - City:PROSSER
Practice Address - State:WA
Practice Address - Zip Code:99350-5653
Practice Address - Country:US
Practice Address - Phone:509-781-2196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-14
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP161438557225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant