Provider Demographics
NPI:1801342118
Name:VAN WAGONER, AARON (DPT)
Entity type:Individual
Prefix:
First Name:AARON
Middle Name:
Last Name:VAN WAGONER
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 1:1021 1ST ST SE
Mailing Address - Street 2:
Mailing Address - City:CUT BANK
Mailing Address - State:MT
Mailing Address - Zip Code:59427-3109
Mailing Address - Country:US
Mailing Address - Phone:702-336-1951
Mailing Address - Fax:
Practice Address - Street 1:615 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CUT BANK
Practice Address - State:MT
Practice Address - Zip Code:59427-2802
Practice Address - Country:US
Practice Address - Phone:406-873-2024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-27
Last Update Date:2016-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPTP-PT-LIC-7729225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist