Provider Demographics
NPI:1780198416
Name:WAGNER, ANDREW HOWARD
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:HOWARD
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 1:120 BRIGGSWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ELMA
Mailing Address - State:NY
Mailing Address - Zip Code:14059-9477
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 BRIGGSWOOD DR
Practice Address - Street 2:
Practice Address - City:ELMA
Practice Address - State:NY
Practice Address - Zip Code:14059-9477
Practice Address - Country:US
Practice Address - Phone:716-432-5113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-16
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL34249225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist