Provider Demographics
NPI:1861040370
Name:WAGNER, PRESTON THOMAS
Entity Type:Individual
Prefix:
First Name:PRESTON
Middle Name:THOMAS
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 1:9602 COLDWATER RD STE 102
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-2095
Mailing Address - Country:US
Mailing Address - Phone:260-436-8454
Mailing Address - Fax:260-489-9121
Practice Address - Street 1:7617 W JEFFERSON BLVD STE D
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4164
Practice Address - Country:US
Practice Address - Phone:260-436-8454
Practice Address - Fax:260-489-9121
Is Sole Proprietor?:No
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05013517A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist