Provider Demographics
NPI:1710702402
Name:WAGONER, KYLE LAWRENCE
Entity type:Individual
Prefix:MR
First Name:KYLE
Middle Name:LAWRENCE
Last Name:WAGONER
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:PSC 808 BOX 431
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09618-0005
Mailing Address - Country:US
Mailing Address - Phone:314-629-6183
Mailing Address - Fax:
Practice Address - Street 1:PSC 808 BOX 431
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09618-0005
Practice Address - Country:US
Practice Address - Phone:314-629-6183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-19
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant