Healthcare Provider Details

I. General information

NPI: 1669451472
Provider Name (Legal Business Name): JUSTIN ROMAN WAGNER PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 10/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

REC CENTER PHYSICAL THERAPY 400 COLLINS RD NE 154-100
CEDAR RAPIDS IA
52498-0001
US

IV. Provider business mailing address

REC CENTER PHYSICAL THERAPY 400 COLLINS RD NE 154-100
CEDAR RAPIDS IA
52498-0001
US

V. Phone/Fax

Practice location:
  • Phone: 319-295-8899
  • Fax: 319-295-8833
Mailing address:
  • Phone: 319-295-8899
  • Fax: 319-295-8833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number03670
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier38070
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerWELLMARK PROVIDER NUMBER

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: