MEDICARE: PATRICIA SUE VANWAGNER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	5028	OR

General Provider Information

NPI Number	:	1114032463
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICIA SUE VANWAGNER

Provider Business Mailing Address
First Line	:	22710 126TH PL SE
Second Line	:
City	:	KENT
State	:	WA
Zip	:	98031-3666
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	201 NW 78TH ST
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98665-7904
Country	:	US
Telephone Number	:	360-694-9686
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	10/08/2007

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