Provider Demographics
NPI:1669284170
Name:WAGNER-HASTON, AMBER M (PT, DPT)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:M
Last Name:WAGNER-HASTON
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 1:4727 E CAMP LOWELL DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-1256
Mailing Address - Country:US
Mailing Address - Phone:520-290-4263
Mailing Address - Fax:
Practice Address - Street 1:1790 E RIVER RD STE 101
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-5958
Practice Address - Country:US
Practice Address - Phone:520-783-3344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-22
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ033984208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation