Healthcare Provider Details

I. General information

NPI: 1821681925
Provider Name (Legal Business Name): NOAH WAGNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2021
Last Update Date: 06/08/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 COPPER ROAD
FRISCO CO
80443
US

IV. Provider business mailing address

305 CHADWYCK LN
LITITZ PA
17543-7451
US

V. Phone/Fax

Practice location:
  • Phone: 888-350-1544
  • Fax:
Mailing address:
  • Phone: 845-476-9824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT.0002450
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: