=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821681925
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NOAH WAGNER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2021
-----------------------------------------------------
Last Update Date | 06/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 505 COPPER ROAD
-----------------------------------------------------
City | FRISCO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-350-1544
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 305 CHADWYCK LN
-----------------------------------------------------
City | LITITZ
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17543-7451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-476-9824
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AT.0002450
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------