Provider Demographics
NPI:1023467206
Name:WAGNER, NOEL C (PT, DPT)
Entity type:Individual
Prefix:
First Name:NOEL
Middle Name:C
Last Name:WAGNER
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 1:4201 N 90TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68134-4136
Mailing Address - Country:US
Mailing Address - Phone:402-934-0045
Mailing Address - Fax:402-934-6562
Practice Address - Street 1:4201 N 90TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68134-4136
Practice Address - Country:US
Practice Address - Phone:402-934-0045
Practice Address - Fax:402-934-6562
Is Sole Proprietor?:No
Enumeration Date:2016-06-08
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3574225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist