MEDICARE: SANDRA M WAGONER OT

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	225XH1200X	Hand Occupational Therapist	0119000123	VA

General Provider Information

NPI Number	:	1518017797
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA M WAGONER OT

Provider Business Mailing Address
First Line	:	PO BOX 1583
Second Line	:
City	:	CHARLOTTESVILLE
State	:	VA
Zip	:	22902-1583
Country	:	US
Telephone Number	:	434-654-7794
Fax Number	:	434-654-7752

Provider Business Practice Location Address
First Line	:	410 ALBEMARLE SQ
Second Line	:
City	:	CHARLOTTESVILLE
State	:	VA
Zip	:	22901-7400
Country	:	US
Telephone Number	:	434-817-4278
Fax Number	:

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

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	12/20/2010

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