Provider Demographics
NPI:1841326907
Name:WAGNER, MELINDA KAY (PT)
Entity type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:KAY
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 1:350 NEW FIDELITY CT
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-2665
Mailing Address - Country:US
Mailing Address - Phone:919-373-2919
Mailing Address - Fax:
Practice Address - Street 1:2000 S GLENBURNIE RD STE 210
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-5227
Practice Address - Country:US
Practice Address - Phone:252-302-5200
Practice Address - Fax:252-302-2191
Is Sole Proprietor?:No
Enumeration Date:2007-02-25
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMO R1111225100000X
NCP21235225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMO R1111OtherPHYSICAL THERAPY LICENSE