Provider Demographics
NPI:1881967016
Name:WAGNER, MARK ALLEN (MPT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALLEN
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4046 AREZZO DR
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-4157
Mailing Address - Country:US
Mailing Address - Phone:303-304-8656
Mailing Address - Fax:
Practice Address - Street 1:4046 AREZZO DR
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-4157
Practice Address - Country:US
Practice Address - Phone:303-304-8656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-19
Last Update Date:2012-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9868225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist