Healthcare Provider Details

I. General information

NPI: 1316125917
Provider Name (Legal Business Name): SAMUEL DUANE WAGNER RRT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2008
Last Update Date: 02/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 1 BOX 281W
THORNTON WV
26440-9721
US

IV. Provider business mailing address

RR 1 BOX 281W
THORNTON WV
26440-9721
US

V. Phone/Fax

Practice location:
  • Phone: 304-265-3032
  • Fax:
Mailing address:
  • Phone: 304-265-3032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License NumberLRTR0128
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: