Provider Demographics
NPI:1629228135
Name:WACKER, MEGAN E (DPT)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:E
Last Name:WACKER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:E
Other - Last Name:RIDDLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:PO BOX 1311
Mailing Address - Street 2:
Mailing Address - City:VAIL
Mailing Address - State:CO
Mailing Address - Zip Code:81658-1311
Mailing Address - Country:US
Mailing Address - Phone:970-476-7510
Mailing Address - Fax:970-476-7511
Practice Address - Street 1:1295 WESTHAVEN DR
Practice Address - Street 2:
Practice Address - City:VAIL
Practice Address - State:CO
Practice Address - Zip Code:81657-4395
Practice Address - Country:US
Practice Address - Phone:970-476-7510
Practice Address - Fax:970-476-7511
Is Sole Proprietor?:No
Enumeration Date:2008-09-22
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8955225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCO8955OtherSTATE LICENSE
COC303619Medicare PIN