Provider Demographics
NPI:1699312363
Name:WAGNER, FARLEY (PT)
Entity type:Individual
Prefix:
First Name:FARLEY
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5931 YAHN RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:14425-9577
Mailing Address - Country:US
Mailing Address - Phone:585-233-2069
Mailing Address - Fax:
Practice Address - Street 1:1160 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NY
Practice Address - Zip Code:14425-9534
Practice Address - Country:US
Practice Address - Phone:585-924-4459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY11097-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist