Individual
LISA WAGONER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
P.T.A.
Contact information
Practice address
400 CRATER LAKE AVE, MEDFORD, OR 97504-6808
(541) 613-6505
Mailing address
113 N ELM ST, CANBY, OR 97013-3519
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
8785
OR
225200000X
Physical Therapy Assistant
PTA-2842
ID
Other
Enumeration date
05/02/2012
Last updated
05/01/2023
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