Provider Demographics
NPI:1912957713
Name:WAGNER, DANIEL M (ATC)
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:M
Last Name:WAGNER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W UNIVERSITY AVE
Mailing Address - Street 2:BOX 912
Mailing Address - City:MITCHELL
Mailing Address - State:SD
Mailing Address - Zip Code:57301-4358
Mailing Address - Country:US
Mailing Address - Phone:605-995-2145
Mailing Address - Fax:605-995-2143
Practice Address - Street 1:1200 W UNIVERSITY AVE
Practice Address - Street 2:BOX 912
Practice Address - City:MITCHELL
Practice Address - State:SD
Practice Address - Zip Code:57301-4358
Practice Address - Country:US
Practice Address - Phone:605-995-2145
Practice Address - Fax:605-995-2143
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD00492255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer