Healthcare Provider Details

I. General information

NPI: 1770511636
Provider Name (Legal Business Name): LINNAE MERITH WAGNER PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 02/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

393 DUNLAP ST N STE LL34
SAINT PAUL MN
55104-4200
US

IV. Provider business mailing address

393 DUNLAP ST N STE LL34
SAINT PAUL MN
55104-4200
US

V. Phone/Fax

Practice location:
  • Phone: 651-644-6002
  • Fax: 651-647-1647
Mailing address:
  • Phone: 651-644-6002
  • Fax: 651-647-1647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number6126
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: