Provider Demographics
NPI:1003141433
Name:WAGONER, MICHELLE RENAE (PT, DPT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENAE
Last Name:WAGONER
Suffix:
Gender:F
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 1:9713 W TONOPAH DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-5110
Mailing Address - Country:US
Mailing Address - Phone:480-381-0220
Mailing Address - Fax:623-594-9094
Practice Address - Street 1:9713 W TONOPAH DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-5110
Practice Address - Country:US
Practice Address - Phone:480-381-0220
Practice Address - Fax:623-594-9094
Is Sole Proprietor?:No
Enumeration Date:2009-10-02
Last Update Date:2009-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8684225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist