Provider Demographics
NPI:1306802087
Name:WAGNER, ANDREW BLAKE (PT)
Entity type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:BLAKE
Last Name:WAGNER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10657 W 200 S
Mailing Address - Street 2:
Mailing Address - City:PARKER CITY
Mailing Address - State:IN
Mailing Address - Zip Code:47368
Mailing Address - Country:US
Mailing Address - Phone:765-468-7297
Mailing Address - Fax:
Practice Address - Street 1:7701 WEST KILGORE
Practice Address - Street 2:STE 1A
Practice Address - City:YORKTOWN
Practice Address - State:IN
Practice Address - Zip Code:47396
Practice Address - Country:US
Practice Address - Phone:765-759-5273
Practice Address - Fax:765-759-5519
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05007376A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist