Provider Demographics
NPI:1457729311
Name:WAGNER, KRISTA KATE (OTR)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:KATE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4770 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746-3718
Mailing Address - Country:US
Mailing Address - Phone:218-966-7204
Mailing Address - Fax:
Practice Address - Street 1:4770 1ST AVE
Practice Address - Street 2:
Practice Address - City:HIBBING
Practice Address - State:MN
Practice Address - Zip Code:55746-3718
Practice Address - Country:US
Practice Address - Phone:218-966-7204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-09
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104783225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN616055700Medicaid