Provider Demographics
NPI:1932143609
Name:ASBURY-WAGNER, HEIDI CHRISTINE (DPT)
Entity Type:Individual
Prefix:MRS
First Name:HEIDI
Middle Name:CHRISTINE
Last Name:ASBURY-WAGNER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MS
Other - First Name:HEIDI
Other - Middle Name:CHRISTINE
Other - Last Name:ASBURY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPT
Mailing Address - Street 1:1794 OLYMPIC PARKWAY
Mailing Address - Street 2:SUITE 140
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84068
Mailing Address - Country:US
Mailing Address - Phone:435-575-0345
Mailing Address - Fax:435-575-0346
Practice Address - Street 1:1794 OLYMPIC PARKWAY
Practice Address - Street 2:SUITE 140
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84068
Practice Address - Country:US
Practice Address - Phone:435-575-0345
Practice Address - Fax:435-575-0346
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8223781-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT8223781-2401OtherUTAH LICENSE
CAPT27508OtherLICENSE NUMBER
UT8223781-2401OtherUTAH LICENSE