Provider Demographics
NPI:1114737608
Name:WAGONER, EMILY
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:WAGONER
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 1:6448 E HWY 290 STE F104
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-1042
Mailing Address - Country:US
Mailing Address - Phone:317-362-3046
Mailing Address - Fax:
Practice Address - Street 1:6448 E HWY 290 STE F104
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-1042
Practice Address - Country:US
Practice Address - Phone:512-298-2856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-08
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14013352251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic