Provider Demographics
NPI:1770962805
Name:WAGNER, RICHARD EARL (DPT)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:EARL
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 1:200 QUEBEC ST BLDG 600
Mailing Address - Street 2:STE 215
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80230-7144
Mailing Address - Country:US
Mailing Address - Phone:303-341-0369
Mailing Address - Fax:303-341-0866
Practice Address - Street 1:200 QUEBEC ST BLDG 600
Practice Address - Street 2:STE 215
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80230-7144
Practice Address - Country:US
Practice Address - Phone:303-341-0369
Practice Address - Fax:303-341-0866
Is Sole Proprietor?:No
Enumeration Date:2015-05-21
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0013597225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPTPL.0000016OtherPROVISDIONAL PHYSICAL THERAPY LICENSE