Provider Demographics
NPI:1588250351
Name:WAGNER, TY'ARA
Entity type:Individual
Prefix:
First Name:TY'ARA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4732 LEBANON RD STE D
Mailing Address - Street 2:
Mailing Address - City:MINT HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28227-9112
Mailing Address - Country:US
Mailing Address - Phone:704-763-2059
Mailing Address - Fax:
Practice Address - Street 1:100 COLUMBIA DR
Practice Address - Street 2:
Practice Address - City:LINWOOD
Practice Address - State:NC
Practice Address - Zip Code:27299-9711
Practice Address - Country:US
Practice Address - Phone:980-267-2965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-16
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17320225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist