Healthcare Provider Details

I. General information

NPI: 1780198416
Provider Name (Legal Business Name): ANDREW HOWARD WAGNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2017
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7108 BOONE ST STE B
FAIRVIEW TN
37062-9305
US

IV. Provider business mailing address

1200 CORPORATE DR STE 400
HOOVER AL
35242-5424
US

V. Phone/Fax

Practice location:
  • Phone: 615-236-7013
  • Fax:
Mailing address:
  • Phone: 423-238-8995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number34249
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number17567
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: