Healthcare Provider Details

I. General information

NPI: 1215326186
Provider Name (Legal Business Name): BRIANNA WAGNER LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2015
Last Update Date: 01/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4176 HILL TERRACE DR
SINKING SPRING PA
19608-9367
US

IV. Provider business mailing address

4176 HILL TERRACE DR
SINKING SPRING PA
19608-9367
US

V. Phone/Fax

Practice location:
  • Phone: 610-301-3977
  • Fax:
Mailing address:
  • Phone: 610-301-3977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT005831
License Number StatePA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: