MEDICARE: MR. SCOTT WAGNER PT

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	4604	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4604	OTHER	MN	MHP
2	HP46100	OTHER	MN	HP

General Provider Information

NPI Number	:	1982648051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SCOTT WAGNER PT

Provider Business Mailing Address
First Line	:	3015 UTAH AVE S
Second Line	:	SUITE 200
City	:	SAINT LOUIS PARK
State	:	MN
Zip	:	55426-3671
Country	:	US
Telephone Number	:	952-933-1121
Fax Number	:	952-945-9635

Provider Business Practice Location Address
First Line	:	3015 UTAH AVE S
Second Line	:	SUITE 200
City	:	SAINT LOUIS PARK
State	:	MN
Zip	:	55426-3671
Country	:	US
Telephone Number	:	952-933-1121
Fax Number	:	952-945-9635

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

Provider Enumeration Date	:	06/16/2006
Last Update Date	:	07/08/2007

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Directions to “ MR. SCOTT WAGNER PT” Practice Location

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