Provider Demographics
NPI:1427130814
Name:WAGNER, ANDREW THOMAS (PT ATC)
Entity type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:THOMAS
Last Name:WAGNER
Suffix:
Gender:M
Credentials:PT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6863 HOLLOPETER RD
Mailing Address - Street 2:
Mailing Address - City:LEO
Mailing Address - State:IN
Mailing Address - Zip Code:46765-9269
Mailing Address - Country:US
Mailing Address - Phone:260-797-2572
Mailing Address - Fax:
Practice Address - Street 1:6863 HOLLOPETER RD
Practice Address - Street 2:
Practice Address - City:LEO
Practice Address - State:IN
Practice Address - Zip Code:46765-9269
Practice Address - Country:US
Practice Address - Phone:260-797-2572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05007988A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist