Provider Demographics
NPI:1700505559
Name:WEGNER, SAMANTHA MARIE
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:MARIE
Last Name:WEGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:SAMANTHA
Other - Middle Name:MARIE
Other - Last Name:EHLERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:702 10TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:DODGE CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55927-9172
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:702 10TH AVE NW
Practice Address - Street 2:
Practice Address - City:DODGE CENTER
Practice Address - State:MN
Practice Address - Zip Code:55927-9172
Practice Address - Country:US
Practice Address - Phone:507-402-3085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-24
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA1736225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
41-0991680OtherCARE CENTER