| Doctor Name: | BLAKE DOUGLAS WAGNER |
| NPI Number: | 1811057664 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PT |
| License Number: | 1004 |
| Business Practice Address: | 3111 Gordon Drive Sioux City, IA - 51106 |
| Business Phone Number: | 7122770507 |
| Business Fax Number: | 7122770456 |
| Mailing Address: | 3111 Gordon Drive, SIOUX CITY |
| State: | IA |
| Postal Code: | 51106 |
| Phone Number: | 7122770507 |
| Fax Number: | 7122770456 |
| NPI Enumeration Date: | 12/11/2006 |
| NPI Last Update Date: | 12/11/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 225100000X |
| License Number: | 1004 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | NE |
| Taxonomy Type: | Respiratory, Developmental, Rehabilitative and Restorative Service Providers |
| Taxonomy Classification: | Physical Therapist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | (1) Physical therapists are health care professionals who evaluate and treat people with health problems resulting from injury or disease. PT |