Provider Demographics
NPI:1538486162
Name:WAGNER, SCOTT ALLEN (MSOTR/L)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:ALLEN
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MSOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 CAPITOL WAY
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-2218
Mailing Address - Country:US
Mailing Address - Phone:701-751-0410
Mailing Address - Fax:
Practice Address - Street 1:1615 CAPITOL WAY
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-2218
Practice Address - Country:US
Practice Address - Phone:701-751-0410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-21
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1131225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics