Provider Demographics
NPI:1639302995
Name:WAGNER, ADRIAN (DPT)
Entity Type:Individual
Prefix:MS
First Name:ADRIAN
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 GROVER ST
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-1748
Mailing Address - Country:US
Mailing Address - Phone:518-378-8207
Mailing Address - Fax:
Practice Address - Street 1:20060 GOVERNORS DR
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1029
Practice Address - Country:US
Practice Address - Phone:708-283-1789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-02
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.017317225100000X
NY031554-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist