Provider Demographics
NPI:1891939344
Name:WAGONER, BLAIR ELLEN
Entity Type:Individual
Prefix:
First Name:BLAIR
Middle Name:ELLEN
Last Name:WAGONER
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 1:115 WEST DR
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:KY
Mailing Address - Zip Code:42071-9830
Mailing Address - Country:US
Mailing Address - Phone:270-293-0758
Mailing Address - Fax:
Practice Address - Street 1:1001 MONARCH ST
Practice Address - Street 2:SUITE 110
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40513-1495
Practice Address - Country:US
Practice Address - Phone:859-224-0834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-28
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT 3141225100000X
KYPT0054122251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist