Provider Demographics
NPI:1386697019
Name:WAGNER, JOHN (ATC)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 WASHINGTON ST
Mailing Address - Street 2:FLOOR 2
Mailing Address - City:CARLSTADT
Mailing Address - State:NJ
Mailing Address - Zip Code:07072-1508
Mailing Address - Country:US
Mailing Address - Phone:201-245-5417
Mailing Address - Fax:
Practice Address - Street 1:35 COLGATE ST
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-3307
Practice Address - Country:US
Practice Address - Phone:201-547-2093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT000837002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer