Provider Demographics
NPI:1437244050
Name:WAGNER, JEFFREY TODD (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:TODD
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 1:1 GATEWAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:WADING RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:11792
Mailing Address - Country:US
Mailing Address - Phone:631-929-9200
Mailing Address - Fax:631-929-9201
Practice Address - Street 1:1 GATEWAY DRIVE
Practice Address - Street 2:
Practice Address - City:WADING RIVER
Practice Address - State:NY
Practice Address - Zip Code:11792
Practice Address - Country:US
Practice Address - Phone:631-929-9200
Practice Address - Fax:631-929-9201
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023281225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY828749OtherMANAGED PHYSICAL NETWORK
NYQN6131OtherBC/BS
NY127516OtherVYTRA
NYQN6131OtherBC/BS