Basic Information
| Provider Information | |||||||||
| NPI: | 1053039016 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | NOLAN | ||||||||
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| Credential: | LAT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6700 COUNTY ROAD J | ||||||||
| Address2: | |||||||||
| City: | STURGEON BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542359336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204953052 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1970 S RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543044125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204304888 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2022 | ||||||||
| LastUpdateDate: | 08/16/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 2289-39 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.