Provider Demographics
NPI:1659057412
Name:WAGNER, MATTHEW AUSTIN
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:AUSTIN
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 1:616 BEDFORD AVE
Mailing Address - Street 2:
Mailing Address - City:BELLMORE
Mailing Address - State:NY
Mailing Address - Zip Code:11710-3619
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:616 BEDFORD AVE
Practice Address - Street 2:
Practice Address - City:BELLMORE
Practice Address - State:NY
Practice Address - Zip Code:11710-3619
Practice Address - Country:US
Practice Address - Phone:516-686-5533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050527225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist