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General NPI Number Information
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NPI Number | 1538018189
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Entity Type | Individual
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Provider Name | MICAIAH WAGNER DPT
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Gender | Male
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Dates
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Enumeration Date | 01/27/2026
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Last Update Date | 01/27/2026
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Provider Practice Location Address
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Address Line | 5400 GARY ST
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City | FORT SMITH
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State | AR
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Zip | 72903-4744
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Country | US
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Telephone | 918-658-0975
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Fax |
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Provider Business Mailing Address
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Address Line | 411 BETTY LOU RD
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City | POTEAU
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State | OK
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Zip | 74953-5221
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Country | US
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Telephone | 918-658-0975
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 6526
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License Number State | OK
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