Provider Demographics
NPI:1750155529
Name:WAGNER, ADAM (DPT)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 E MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:TRUMANSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14886-8908
Mailing Address - Country:US
Mailing Address - Phone:607-213-3300
Mailing Address - Fax:
Practice Address - Street 1:203 E MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:TRUMANSBURG
Practice Address - State:NY
Practice Address - Zip Code:14886-8908
Practice Address - Country:US
Practice Address - Phone:607-213-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0516032251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty