Individual
CHARLES TOM WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PT
Contact information
Practice address
754 N COLLEGE RD, STE D, TWIN FALLS, ID 83301-5822
(208) 734-5313
(208) 736-1582
Mailing address
754 N COLLEGE RD, STE D, TWIN FALLS, ID 83301-5822
(208) 734-5313
(208) 736-1582
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
RPT-208
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
002620200
—
ID
Enumeration date
12/19/2006
Last updated
04/05/2013
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