Individual
BRAD WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
4706 AERO PKWY, FLORENCE, KY 41042-2994
(513) 431-9305
Mailing address
4706 AERO PKWY, FLORENCE, KY 41042-2994
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
AT1725
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
AT1725
KENTUCKY BOARD OF MEDICAL LICENSURE
KY
Enumeration date
02/24/2020
Last updated
02/24/2020
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