Provider Demographics
NPI:1437712700
Name:WAGNER, WAYNE SCOTT
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:SCOTT
Last Name:WAGNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S CRAPO ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-2944
Mailing Address - Country:US
Mailing Address - Phone:989-773-5918
Mailing Address - Fax:989-772-0248
Practice Address - Street 1:400 S CRAPO ST
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-2944
Practice Address - Country:US
Practice Address - Phone:989-773-5918
Practice Address - Fax:989-772-0248
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-22
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224Z00000X
MI5202005126224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5202005126Medicaid