MEDICARE: ANDREW WAGLER

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	225200000X	Physical Therapy Assistant	005085	IA

General Provider Information

NPI Number	:	1790182756
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREW WAGLER

Provider Business Mailing Address
First Line	:	1515 E WASHINGTON ST
Second Line	:
City	:	MOUNT PLEASANT
State	:	IA
Zip	:	52641-1857
Country	:	US
Telephone Number	:	319-931-1210
Fax Number	:

Provider Business Practice Location Address
First Line	:	1515 E WASHINGTON ST
Second Line	:	APT. 102
City	:	MOUNT PLEASANT
State	:	IA
Zip	:	52641-1857
Country	:	US
Telephone Number	:	319-931-1210
Fax Number	:

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

Provider Enumeration Date	:	11/19/2014
Last Update Date	:	11/19/2014

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