Provider Demographics
NPI:1215332705
Name:WAGNER, PATRICIA ANNE
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ANNE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:ANNE
Other - Last Name:HUSSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1401 BLACKFOOT TRL
Mailing Address - Street 2:
Mailing Address - City:WOODLAND PARK
Mailing Address - State:CO
Mailing Address - Zip Code:80863-8304
Mailing Address - Country:US
Mailing Address - Phone:719-686-1938
Mailing Address - Fax:
Practice Address - Street 1:1401 BLACKFOOT TRL
Practice Address - Street 2:
Practice Address - City:WOODLAND PARK
Practice Address - State:CO
Practice Address - Zip Code:80863-8304
Practice Address - Country:US
Practice Address - Phone:719-686-1938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO33482255R0406X
CO3518225CX0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225CX0006XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorOrientation and Mobility Training Provider
No2255R0406XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistRehabilitation, Blind