Individual
SAMANTHA ANN WAGNER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
ATC, LAT, CES
Contact information
Practice address
170 ATHLETIC CTR, STILLWATER, OK 74078-0001
(405) 744-7823
Mailing address
4599 N WASHINGTON ST, APT 4F, STILLWATER, OK 74075-1278
(937) 308-6354
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
914
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
914
OKLAHOMA STATE BOARD OF MEDICAL LICENSURE AND SUPERVISION
OK
Enumeration date
02/29/2016
Last updated
02/29/2016
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