MEDICARE: JOHN WAGNER DPT

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	2251X0800X	Orthopedic Physical Therapist	004345	IA

General Provider Information

NPI Number	:	1427383975
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN WAGNER DPT

Provider Business Mailing Address
First Line	:	3098 23RD AVE
Second Line	:
City	:	MARION
State	:	IA
Zip	:	52302-1607
Country	:	US
Telephone Number	:	319-899-8387
Fax Number	:

Provider Business Practice Location Address
First Line	:	9964 W 144TH ST
Second Line	:
City	:	ORLAND PARK
State	:	IL
Zip	:	60462-2458
Country	:	US
Telephone Number	:	708-460-8027
Fax Number	:

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

Provider Enumeration Date	:	10/15/2009
Last Update Date	:	10/15/2009

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