Individual
BLAKE DOUGLAS WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PT
Contact information
Practice address
410 E 22ND ST STE 2, FREMONT, NE 68025-2640
(800) 974-4378
(630) 515-1536
Mailing address
24014 W RENWICK RD UNIT 206, PLAINFIELD, IL 60544-8711
(800) 974-4378
(630) 515-1536
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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