Provider Demographics
NPI:1821681925
Name:WAGNER, NOAH
Entity Type:Individual
Prefix:
First Name:NOAH
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 1:305 CHADWYCK LN
Mailing Address - Street 2:
Mailing Address - City:LITITZ
Mailing Address - State:PA
Mailing Address - Zip Code:17543-7451
Mailing Address - Country:US
Mailing Address - Phone:845-476-9824
Mailing Address - Fax:
Practice Address - Street 1:505 COPPER ROAD
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:CO
Practice Address - Zip Code:80443
Practice Address - Country:US
Practice Address - Phone:888-350-1544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-19
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAT.00024502255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000051106OtherBOC
COAT.0002450OtherCOLORADO DEPARTMENT OF REGULATORY AGENCIES
PA304994OtherNATA