1811057664 NPI number — BLAKE DOUGLAS WAGNER PT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811057664 NPI number — BLAKE DOUGLAS WAGNER PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAGNER
Provider First Name:
BLAKE
Provider Middle Name:
DOUGLAS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811057664
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24014 W RENWICK RD UNIT 206
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLAINFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60544-8711
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-974-4378
Provider Business Mailing Address Fax Number:
630-515-1536

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
410 E 22ND ST STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREMONT
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68025-2640
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-974-4378
Provider Business Practice Location Address Fax Number:
630-515-1536
Provider Enumeration Date:
12/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  01883 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 1004 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 29675 . This is a "BCBS IA-WELLMARK" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 0762989 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00636067 . This is a "RR MEDICARE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com