Provider Demographics
NPI:1710033097
Name:WAGNER, AMY E (PT)
Entity type:Individual
Prefix:MS
First Name:AMY
Middle Name:E
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 N MONTEREY ST
Mailing Address - Street 2:APT. L
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-1596
Mailing Address - Country:US
Mailing Address - Phone:626-394-9673
Mailing Address - Fax:626-293-3370
Practice Address - Street 1:1428 S MARENGO AVE
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91803-3001
Practice Address - Country:US
Practice Address - Phone:626-576-1032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25461225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist