Basic Information
| Provider Information | |||||||||
| NPI: | 1053433128 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MSPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 516 GREENWICH ST | ||||||||
| Address2: | |||||||||
| City: | FALLS CHURCH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220462501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7035878670 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6849 OLD DOMINION DR | ||||||||
| Address2: | |||||||||
| City: | MCLEAN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221013724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038489333 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | 2305202514 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No ID Information.