Provider Demographics
NPI:1841339132
Name:WAGNER, TODD J (MSPT)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:J
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:WHITNEY
Mailing Address - State:TX
Mailing Address - Zip Code:76692-0068
Mailing Address - Country:US
Mailing Address - Phone:254-694-6831
Mailing Address - Fax:
Practice Address - Street 1:204 E JEFFERSON
Practice Address - Street 2:
Practice Address - City:WHITNEY
Practice Address - State:TX
Practice Address - Zip Code:76692
Practice Address - Country:US
Practice Address - Phone:254-694-6831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1123479225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX161076801Medicaid
TX8A8623Medicare ID - Type UnspecifiedMEDICARE
TX161076801Medicaid