Provider Demographics
NPI:1770834541
Name:WAGNER, ALYSON MARGARET (DPT)
Entity Type:Individual
Prefix:DR
First Name:ALYSON
Middle Name:MARGARET
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3530 HENRY HUDSON PKWY
Mailing Address - Street 2:APT PHB
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-1306
Mailing Address - Country:US
Mailing Address - Phone:917-612-1264
Mailing Address - Fax:
Practice Address - Street 1:3530 HENRY HUDSON PKWY
Practice Address - Street 2:APT PHB
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-1306
Practice Address - Country:US
Practice Address - Phone:917-612-1264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035121225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY$$$$$$$$$Medicaid