Provider Demographics
NPI:1467974659
Name:WAGNER, SANDRA LAUREEN (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LAUREEN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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Mailing Address - Street 1:15004 204TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98059-8916
Mailing Address - Country:US
Mailing Address - Phone:206-409-6854
Mailing Address - Fax:
Practice Address - Street 1:30252 TOMAS STE 100
Practice Address - Street 2:
Practice Address - City:RANCHO SANTA MARGARITA
Practice Address - State:CA
Practice Address - Zip Code:92688-2181
Practice Address - Country:US
Practice Address - Phone:949-459-1658
Practice Address - Fax:949-459-1667
Is Sole Proprietor?:No
Enumeration Date:2017-07-10
Last Update Date:2017-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics