Provider Demographics
NPI:1801000781
Name:WAGENET, MEGAN
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:WAGENET
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:GANNETT HEALTH SERVICES
Mailing Address - Street 2:110 HO PLAZA
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14853-3101
Mailing Address - Country:US
Mailing Address - Phone:607-255-6106
Mailing Address - Fax:607-254-3503
Practice Address - Street 1:GANNETT HEALTH SERVICES
Practice Address - Street 2:110 HO PLAZA
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14853-3101
Practice Address - Country:US
Practice Address - Phone:607-255-6106
Practice Address - Fax:607-254-3503
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023641-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist