Provider Demographics
NPI:1932975521
Name:WAGNER, LAURA (DPT, PT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E 2ND AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-1718
Mailing Address - Country:US
Mailing Address - Phone:386-763-0084
Mailing Address - Fax:386-763-0085
Practice Address - Street 1:401 VENTURE DR STE B
Practice Address - Street 2:
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-3475
Practice Address - Country:US
Practice Address - Phone:386-763-0084
Practice Address - Fax:386-763-0085
Is Sole Proprietor?:No
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT40959225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist