Provider Demographics
NPI:1528155991
Name:WAGNER, STEVEN GLENN
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:GLENN
Last Name:WAGNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 S SHOOP AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSEON
Mailing Address - State:OH
Mailing Address - Zip Code:43567-1735
Mailing Address - Country:US
Mailing Address - Phone:419-335-2663
Mailing Address - Fax:419-335-9615
Practice Address - Street 1:735 S SHOOP AVE
Practice Address - Street 2:
Practice Address - City:WAUSEON
Practice Address - State:OH
Practice Address - Zip Code:43567-1735
Practice Address - Country:US
Practice Address - Phone:419-335-2663
Practice Address - Fax:419-335-9615
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH06511225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000391994OtherANTHEM
OH2520721Medicaid
OHP00097926OtherRAILROAD MEDICARE
OH4131071Medicare PIN