Provider Demographics
NPI:1770943078
Name:WAGNER, SAMANTHA ANN (ATC, LAT, CES)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ANN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:ATC, LAT, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4599 N WASHINGTON ST
Mailing Address - Street 2:APT 4F
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74075-1278
Mailing Address - Country:US
Mailing Address - Phone:937-308-6354
Mailing Address - Fax:
Practice Address - Street 1:170 ATHLETIC CTR
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74078-0001
Practice Address - Country:US
Practice Address - Phone:405-744-7823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-29
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9142255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK914OtherOKLAHOMA STATE BOARD OF MEDICAL LICENSURE AND SUPERVISION