Individual
JACOB WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
ATC
Contact information
Practice address
211 OLD LEXINGTON RD, THOMASVILLE, NC 27360-3428
(704) 576-9298
Mailing address
474 STRATFORD RD, LEXINGTON, NC 27292-9653
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
2336
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2336
NCBATE LICENSE
NC
Enumeration date
07/07/2022
Last updated
07/07/2022
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