Provider Demographics
NPI:1902646698
Name:WAGANFEALD, ALICIA MARIE (PTA)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:MARIE
Last Name:WAGANFEALD
Suffix:
Gender:F
Credentials:PTA
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Other - Credentials:
Mailing Address - Street 1:1805 MILTON AVE APT 127C
Mailing Address - Street 2:
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307-2612
Mailing Address - Country:US
Mailing Address - Phone:989-359-9417
Mailing Address - Fax:
Practice Address - Street 1:600 DENMARK ST
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:MI
Practice Address - Zip Code:49304-7500
Practice Address - Country:US
Practice Address - Phone:231-745-4648
Practice Address - Fax:231-745-3724
Is Sole Proprietor?:No
Enumeration Date:2024-05-29
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI55020085882081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine