Healthcare Provider Details

I. General information

NPI: 1114840428
Provider Name (Legal Business Name): SKYLAR RAY WAGNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

616 ALBEMARLE RD STE B
ASHEBORO NC
27203-6259
US

IV. Provider business mailing address

616 ALBEMARLE RD STE B
ASHEBORO NC
27203-6259
US

V. Phone/Fax

Practice location:
  • Phone: 336-953-7049
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number000033390558
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: