Provider Demographics
NPI:1306804448
Name:WAGNER, JAMES BLAKE (PT)
Entity type:Individual
Prefix:
First Name:JAMES
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 1:1525 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72120-5076
Mailing Address - Country:US
Mailing Address - Phone:501-978-3135
Mailing Address - Fax:501-978-3138
Practice Address - Street 1:1525 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:AR
Practice Address - Zip Code:72120-5076
Practice Address - Country:US
Practice Address - Phone:501-978-3135
Practice Address - Fax:501-978-3138
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT25652251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5W797C153OtherAR BLUE CROSS BLUE SHIELD
AR5W797C153OtherAR BLUE CROSS BLUE SHIELD