Provider Demographics
NPI:1740529437
Name:WAGLE, AMARISH A (PT)
Entity type:Individual
Prefix:MR
First Name:AMARISH
Middle Name:A
Last Name:WAGLE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3479 FREDERICK DR
Mailing Address - Street 2:
Mailing Address - City:TOANO
Mailing Address - State:VA
Mailing Address - Zip Code:23168-9362
Mailing Address - Country:US
Mailing Address - Phone:909-362-1363
Mailing Address - Fax:
Practice Address - Street 1:1811 JAMESTOWN RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-2326
Practice Address - Country:US
Practice Address - Phone:757-229-9991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-31
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305206222225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist