Provider Demographics
NPI:1194153577
Name:WAGENER, PHILIP
Entity type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:
Last Name:WAGENER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:PHILIP
Other - Middle Name:HENRY
Other - Last Name:WAGENER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:870 DRIVER RD
Mailing Address - Street 2:
Mailing Address - City:MARRIOTTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21104-1325
Mailing Address - Country:US
Mailing Address - Phone:443-262-2576
Mailing Address - Fax:
Practice Address - Street 1:4730 ATRIUM CT
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-3556
Practice Address - Country:US
Practice Address - Phone:410-363-4790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-23
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA2516225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant