Basic Information
| Provider Information | |||||||||
| NPI: | 1518017797 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGONER | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1583 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229021583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4346547794 | ||||||||
| FaxNumber: | 4346547752 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 ALBEMARLE SQ | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229017400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4348174278 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 12/20/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XH1200X | 0119000123 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand |
No ID Information.