Provider Demographics
NPI:1669451472
Name:WAGNER, JUSTIN ROMAN (PT)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:ROMAN
Last Name:WAGNER
Suffix:
Gender:M
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:REC CENTER PHYSICAL THERAPY
Mailing Address - Street 2:400 COLLINS RD NE 154-100
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52498-0001
Mailing Address - Country:US
Mailing Address - Phone:319-295-8899
Mailing Address - Fax:319-295-8833
Practice Address - Street 1:REC CENTER PHYSICAL THERAPY
Practice Address - Street 2:400 COLLINS RD NE 154-100
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52498-0001
Practice Address - Country:US
Practice Address - Phone:319-295-8899
Practice Address - Fax:319-295-8833
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03670174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA38070OtherWELLMARK PROVIDER NUMBER
IA38070OtherWELLMARK PROVIDER NUMBER