Provider Demographics
NPI:1184178006
Name:WAGNER, ERICA MARIE (PT)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:MARIE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:MARIE
Other - Last Name:HETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1000 E 1ST ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-2297
Mailing Address - Country:US
Mailing Address - Phone:218-625-2728
Mailing Address - Fax:218-722-6515
Practice Address - Street 1:1000 E 1ST ST
Practice Address - Street 2:SUITE 400
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-2297
Practice Address - Country:US
Practice Address - Phone:218-625-2728
Practice Address - Fax:218-722-6515
Is Sole Proprietor?:No
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist