Provider Demographics
NPI:1730483249
Name:WAGNER, THOMAS
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
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 1:11315 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817-8344
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11315 CORPORATE BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-8344
Practice Address - Country:US
Practice Address - Phone:800-774-7785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-28
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist