Provider Demographics
NPI:1659337822
Name:WAGNER, NICOLE T (PT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:T
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2209 QUARRY DR
Mailing Address - Street 2:B-23
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19609-1155
Mailing Address - Country:US
Mailing Address - Phone:610-678-9949
Mailing Address - Fax:610-678-9636
Practice Address - Street 1:2209 QUARRY DR
Practice Address - Street 2:B 23
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19609-1155
Practice Address - Country:US
Practice Address - Phone:610-678-9949
Practice Address - Fax:610-678-9636
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2007-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT013927L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50053282OtherCAPITAL BC
PAWA1749717OtherHIGHMARK BC/BS
PAWA1749717OtherHIGHMARK BC/BS