Provider Demographics
NPI:1043032154
Name:WAGNER, TANNER KEITH
Entity type:Individual
Prefix:
First Name:TANNER
Middle Name:KEITH
Last Name:WAGNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20716 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:GRUNDY
Mailing Address - State:VA
Mailing Address - Zip Code:24614-6747
Mailing Address - Country:US
Mailing Address - Phone:276-935-6496
Mailing Address - Fax:
Practice Address - Street 1:20716 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:GRUNDY
Practice Address - State:VA
Practice Address - Zip Code:24614-6747
Practice Address - Country:US
Practice Address - Phone:276-935-6496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119010676225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist