Provider Demographics
NPI:1518003995
Name:WAGNER, KIMBERLY THOMAS (PT)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:THOMAS
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 1:517 8TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST JOE
Mailing Address - State:FL
Mailing Address - Zip Code:32456-1715
Mailing Address - Country:US
Mailing Address - Phone:352-317-7180
Mailing Address - Fax:
Practice Address - Street 1:3801 E HIGHWAY 98
Practice Address - Street 2:
Practice Address - City:PORT ST JOE
Practice Address - State:FL
Practice Address - Zip Code:32456-5318
Practice Address - Country:US
Practice Address - Phone:850-229-5752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT17258225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
106774Medicare ID - Type Unspecified