Provider Demographics
NPI:1477895498
Name:WAGNER, LYNSEY (PT)
Entity Type:Individual
Prefix:
First Name:LYNSEY
Middle Name:
Last Name:WAGNER
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 1:16083 SW UPPER BOONES FERRY RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:2635 CALDWELL BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-6407
Practice Address - Country:US
Practice Address - Phone:208-442-0577
Practice Address - Fax:208-442-7455
Is Sole Proprietor?:No
Enumeration Date:2013-03-18
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-3048225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0330327OtherWA L&I
ID1477895498Medicaid
IDP01270232OtherRR MEDICARE
ID0330327OtherWA L&I