MEDICARE: MR. JOHN WAGNER ATC

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	2255A2300X	Athletic Trainer	25MT00083700	NJ

General Provider Information

NPI Number	:	1386697019
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN WAGNER ATC

Provider Business Mailing Address
First Line	:	510 WASHINGTON ST
Second Line	:	FLOOR 2
City	:	CARLSTADT
State	:	NJ
Zip	:	07072-1508
Country	:	US
Telephone Number	:	201-245-5417
Fax Number	:

Provider Business Practice Location Address
First Line	:	35 COLGATE ST
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07302-3307
Country	:	US
Telephone Number	:	201-547-2093
Fax Number	:

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

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	04/29/2008

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