Provider Demographics
NPI:1932666336
Name:WAGNER, TAYLOR KAYE ERICKSON
Entity Type:Individual
Prefix:MISS
First Name:TAYLOR
Middle Name:KAYE ERICKSON
Last Name:WAGNER
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 1:1010 NORSTAD RD
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-9769
Mailing Address - Country:US
Mailing Address - Phone:920-973-7600
Mailing Address - Fax:
Practice Address - Street 1:533 E CALUMET ST # 2
Practice Address - Street 2:
Practice Address - City:CHILTON
Practice Address - State:WI
Practice Address - Zip Code:53014-1649
Practice Address - Country:US
Practice Address - Phone:920-849-8529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-22
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI278519225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant