Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | PTA-09596 | OH |
NPI | 1003224478 |
---|---|
Provider Name | Beth Wagner |
First Address | Canton, OH 44718-3602 |
Second Address | Canton, OH 44718-3602 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/07/2014 |
Last Update Date | 29/07/2014 |