Provider Demographics
NPI:1932389780
Name:WAGNER, CHRISTINE KAY IV (PTA)
Entity Type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:KAY
Last Name:WAGNER
Suffix:IV
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 E PARK ST
Mailing Address - Street 2:
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501-4154
Mailing Address - Country:US
Mailing Address - Phone:605-224-8628
Mailing Address - Fax:605-224-6948
Practice Address - Street 1:950 E PARK ST
Practice Address - Street 2:
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501-4154
Practice Address - Country:US
Practice Address - Phone:605-224-8628
Practice Address - Fax:605-224-6948
Is Sole Proprietor?:No
Enumeration Date:2007-11-09
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD00472251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics