Provider Demographics
NPI:1942561543
Name:WAGAN, DAISY J (PT)
Entity Type:Individual
Prefix:
First Name:DAISY
Middle Name:J
Last Name:WAGAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:DAISY
Other - Middle Name:S
Other - Last Name:JUSAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1840 STRAWBERRY RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-7773
Mailing Address - Country:US
Mailing Address - Phone:314-583-7334
Mailing Address - Fax:
Practice Address - Street 1:1840 STRAWBERRY RIDGE DR
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63021-7773
Practice Address - Country:US
Practice Address - Phone:314-583-7334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-31
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORO756225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist