Individual
LYNSEY WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PT
Contact information
Practice address
2635 CALDWELL BLVD, SUITE B, NAMPA, ID 83651-6407
(208) 442-0577
(208) 442-7455
Mailing address
16083 SW UPPER BOONES FERRY RD, SUITE 300, TIGARD, OR 97224-7736
(800) 219-8835
(503) 639-9699
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
PT-3048
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0330327
WA L&I
ID
05
—
1477895498
—
ID
01
—
P01270232
RR MEDICARE
ID
Enumeration date
03/18/2013
Last updated
10/09/2014
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