Provider Demographics
NPI:1174899884
Name:WAGNER, WILLIAM ALBERT JR (PTA)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:ALBERT
Last Name:WAGNER
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6455 PEARL RD
Mailing Address - Street 2:
Mailing Address - City:PARMA HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130-2984
Mailing Address - Country:US
Mailing Address - Phone:440-887-5705
Mailing Address - Fax:
Practice Address - Street 1:6455 PEARL RD
Practice Address - Street 2:
Practice Address - City:PARMA HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-2984
Practice Address - Country:US
Practice Address - Phone:440-887-5705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-27
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4905225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant