Healthcare Provider Details

I. General information

NPI: 1487828570
Provider Name (Legal Business Name): DEREK WAGNER DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2008
Last Update Date: 04/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2032 NEW CASTLE AVE
NEW CASTLE DE
19720-7703
US

IV. Provider business mailing address

1812 MARSH RD STORE 505
WILMINGTON DE
19810-4581
US

V. Phone/Fax

Practice location:
  • Phone: 302-654-1700
  • Fax:
Mailing address:
  • Phone: 302-793-0432
  • Fax: 302-793-0400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA01275800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: