Individual
MR. AUSTIN MICHAEL WAGNER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
ATC
Contact information
Practice address
6300 JAMES S MCDONNELL BLVD, SAINT LOUIS, MO 63134-1940
(314) 232-8702
Mailing address
219 STILLBROOK ESTATES DR, FENTON, MO 63026-6505
(314) 960-1037
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
2018009147
MO
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2018009147
ATHLETIC TRAINER
MO
Enumeration date
07/13/2016
Last updated
08/02/2022
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