MEDICARE: MICAIAH 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	225100000X	Physical Therapist	6526	OK

General Provider Information

NPI Number	:	1538018189
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICAIAH WAGNER DPT

Provider Business Mailing Address
First Line	:	411 BETTY LOU RD
Second Line	:
City	:	POTEAU
State	:	OK
Zip	:	74953-5221
Country	:	US
Telephone Number	:	918-658-0975
Fax Number	:

Provider Business Practice Location Address
First Line	:	5400 GARY ST
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903-4744
Country	:	US
Telephone Number	:	918-658-0975
Fax Number	:

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

Provider Enumeration Date	:	01/27/2026
Last Update Date	:	01/27/2026

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