Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251X0800X | Physical Therapist - Orthopedic | 2305202514 | VA |
NPI | 1053433128 |
---|---|
Provider Name | Mr. Scott Wagner |
First Address | Falls Church, VA 22046-2501 |
Second Address | Mclean, VA 22101-3724 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/04/2007 |
Last Update Date | 08/07/2007 |