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NPI Code Detail

MEDICARE: JENNIFER RAE WAGNER MA, LAT

MEDICARE: JENNIFER RAE WAGNER MA, LAT
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
12255A2300XAthletic Trainer1002-39WI

General Provider Information

NPI Number : 1174582274
Entity Type Code : Individual
Provider Name (Legal Business Name) : JENNIFER RAE WAGNER MA, LAT
Provider Business Mailing Address
First Line : 507 S MONROE ST
Second Line :
City : LANCASTER
State : WI
Zip : 53813-2054
Country : US
Telephone Number : 608-723-3236
Fax Number : 608-723-3379
Provider Business Practice Location Address
First Line : 507 S MONROE ST
Second Line :
City : LANCASTER
State : WI
Zip : 53813-2054
Country : US
Telephone Number : 608-723-3236
Fax Number : 608-723-3379
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/20/2006
Last Update Date : 04/16/2014

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Directions to “ JENNIFER RAE WAGNER MA, LAT” Practice Location

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