Provider Demographics
NPI:1487828570
Name:WAGNER, DEREK (DPT)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1812 MARSH RD
Mailing Address - Street 2:STORE 505
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19810-4581
Mailing Address - Country:US
Mailing Address - Phone:302-793-0432
Mailing Address - Fax:302-793-0400
Practice Address - Street 1:2032 NEW CASTLE AVE
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:DE
Practice Address - Zip Code:19720-7703
Practice Address - Country:US
Practice Address - Phone:302-654-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-18
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01275800225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ126199DBDOtherMEDICARE
MDP01013263OtherMCRR