MEDICARE: MS. KAREN KAY WAGNER PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	1037927	TX

General Provider Information

NPI Number	:	1861708729
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KAREN KAY WAGNER PT

Provider Business Mailing Address
First Line	:	1904 BURBANK ST
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78757-2818
Country	:	US
Telephone Number	:	512-517-5379
Fax Number	:	512-452-6176

Provider Business Practice Location Address
First Line	:	1904 BURBANK ST
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78757-2818
Country	:	US
Telephone Number	:	512-517-5379
Fax Number	:	512-452-6176

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/29/2010
Last Update Date	:	08/29/2010

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