Provider Demographics
NPI:1962029074
Name:WAGAR, BENJAMIN JON STERLING (PT, DPT)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:JON STERLING
Last Name:WAGAR
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:IA
Mailing Address - Zip Code:52342-2307
Mailing Address - Country:US
Mailing Address - Phone:641-484-5253
Mailing Address - Fax:641-484-5312
Practice Address - Street 1:1307 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:IA
Practice Address - Zip Code:52342-2307
Practice Address - Country:US
Practice Address - Phone:641-484-5253
Practice Address - Fax:641-484-5312
Is Sole Proprietor?:No
Enumeration Date:2020-07-06
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA099907225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist