Provider Demographics
NPI:1871660274
Name:WAGNER, CHRISTINE LOUISE (PTA)
Entity Type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:LOUISE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 SUBURBAN PKWY
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02889-9721
Mailing Address - Country:US
Mailing Address - Phone:401-487-2027
Mailing Address - Fax:
Practice Address - Street 1:42 SUBURBAN PKWY
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02889-9721
Practice Address - Country:US
Practice Address - Phone:401-487-2027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPTA00539225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant