Provider Demographics
NPI:1770511636
Name:WAGNER, LINNAE MERITH (PT)
Entity Type:Individual
Prefix:MRS
First Name:LINNAE
Middle Name:MERITH
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 1:393 DUNLAP ST N
Mailing Address - Street 2:STE LL34
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-4200
Mailing Address - Country:US
Mailing Address - Phone:651-644-6002
Mailing Address - Fax:651-647-1647
Practice Address - Street 1:393 DUNLAP ST N
Practice Address - Street 2:STE LL34
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4200
Practice Address - Country:US
Practice Address - Phone:651-644-6002
Practice Address - Fax:651-647-1647
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6126174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN650001476Medicare ID - Type Unspecified