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Individual
ANDREW WAGNER
Active
Individual
ANDREW WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
6070-24
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
11014100
—
WI
05
—
11014110
—
WI
01
—
390848401050
BLUE CROSS
WI
01
—
6070-24
LICENSE NUMBER
WI
Enumeration date
04/08/2008
Last updated
04/14/2008
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