Provider Demographics
NPI:1487806568
Name:WAGLEY, RONNIE A JR (MPT)
Entity type:Individual
Prefix:MR
First Name:RONNIE
Middle Name:A
Last Name:WAGLEY
Suffix:JR
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 ISADORE ST
Mailing Address - Street 2:
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-5747
Mailing Address - Country:US
Mailing Address - Phone:318-238-2820
Mailing Address - Fax:318-238-2811
Practice Address - Street 1:1005 FISHER RD
Practice Address - Street 2:
Practice Address - City:MANY
Practice Address - State:LA
Practice Address - Zip Code:71449-3833
Practice Address - Country:US
Practice Address - Phone:318-256-0800
Practice Address - Fax:318-238-2811
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA04564225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA04564OtherLOUISIANA STATE BOARD OF PHYSICAL THERAPY EXAMINERS