Provider Demographics
NPI:1396394342
Name:VAN WAGNER, ERIN (PTA)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:
Last Name:VAN WAGNER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1196 S BEECHAM RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08094-2163
Mailing Address - Country:US
Mailing Address - Phone:856-889-7619
Mailing Address - Fax:
Practice Address - Street 1:212 MARTER AVE
Practice Address - Street 2:
Practice Address - City:MOORESTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08057-3114
Practice Address - Country:US
Practice Address - Phone:856-291-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00362100225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant