Provider Demographics
NPI:1568022838
Name:WAGNER, DREW
Entity Type:Individual
Prefix:
First Name:DREW
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 218
Mailing Address - Street 2:
Mailing Address - City:MIDDLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49333-0218
Mailing Address - Country:US
Mailing Address - Phone:269-795-4230
Mailing Address - Fax:269-795-4191
Practice Address - Street 1:4624 N M 37 HWY STE A
Practice Address - Street 2:
Practice Address - City:MIDDLEVILLE
Practice Address - State:MI
Practice Address - Zip Code:49333-8163
Practice Address - Country:US
Practice Address - Phone:269-795-4230
Practice Address - Fax:269-795-4191
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501019140225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist