Provider Demographics
NPI:1104297175
Name:WAGNER, RACHEL ANN
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:ANN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12110 BUSINESS BLVD
Mailing Address - Street 2:STE 6 PMB 413
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-7741
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12812 OLD GLENN HWY
Practice Address - Street 2:STE A5
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7002
Practice Address - Country:US
Practice Address - Phone:907-317-9349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-15
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101078225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant