Provider Demographics
NPI:1316125917
Name:WAGNER, SAMUEL DUANE (RRT)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:DUANE
Last Name:WAGNER
Suffix:
Gender:M
Credentials:RRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 281W
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:WV
Mailing Address - Zip Code:26440-9721
Mailing Address - Country:US
Mailing Address - Phone:304-265-3032
Mailing Address - Fax:
Practice Address - Street 1:RR 1 BOX 281W
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:WV
Practice Address - Zip Code:26440-9721
Practice Address - Country:US
Practice Address - Phone:304-265-3032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-06
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVLRTR0128227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered