MEDICARE: MRS. JANET WAGNER

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	224Z00000X	Occupational Therapy Assistant	006077-1	NY

General Provider Information

NPI Number	:	1437483245
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JANET WAGNER

Provider Business Mailing Address
First Line	:	PO BOX 412
Second Line	:
City	:	JEFFERSONVILLE
State	:	NY
Zip	:	12748-0412
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	16 OLD COUNTY RD 128
Second Line	:
City	:	JEFFERSONVILLE
State	:	NY
Zip	:	12748
Country	:	US
Telephone Number	:	845-807-1132
Fax Number	:

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

Provider Enumeration Date	:	09/25/2009
Last Update Date	:	08/24/2013

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