Provider Demographics
NPI:1386659902
Name:WAGAR, COLLEEN M (PT)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:M
Last Name:WAGAR
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1691 OLD HARMONY DR NW
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-8031
Mailing Address - Country:US
Mailing Address - Phone:704-674-9346
Mailing Address - Fax:
Practice Address - Street 1:16455 STATESVILLE RD
Practice Address - Street 2:SUITE 300
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-7135
Practice Address - Country:US
Practice Address - Phone:704-801-3719
Practice Address - Fax:704-801-3705
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8451225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7211860Medicaid
NCE1251OtherMEDCOST NC
NC079PUOtherBCBS NC