Provider Demographics
NPI:1831907708
Name:WAGNER, DYLAN KURT (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:DYLAN
Middle Name:KURT
Last Name:WAGNER
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3553 N FILLMORE ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80205-4259
Mailing Address - Country:US
Mailing Address - Phone:321-412-3404
Mailing Address - Fax:
Practice Address - Street 1:2150 STADIUM DRIVE 2ND FLOOR
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80309-0001
Practice Address - Country:US
Practice Address - Phone:303-315-9900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-24
Last Update Date:2024-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL00202982251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic