Individual
BLAKE DOUGLAS WAGNER
Active
Individual
BLAKE DOUGLAS WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PT
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
01883
IA
225100000X
Physical Therapist
Primary
1004
NE
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0762989
—
IA
01
—
29675
BCBS IA-WELLMARK
IA
01
—
P00636067
RR MEDICARE
IA
Enumeration date
12/11/2006
Last updated
10/30/2023
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