Ethan James Wagner, DPT

Primary specialty

Physical TherapistTaxonomy code 225100000X

License

PT5585 Issued in AR

Practice address

20320 I 30 # 190
Benton, AR 72019-8027

Phone

(501) 500-8188

NPI assigned

Nov 11, 2024

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in AR

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Serc Rehabilitation Partners, LLC

  • Physical Therapist
  • Belton, MO
  • NPI 1760745244

  AR, Physical Therapist

  Medicare reassignment NPD
• Serc Rebabilitation Partners, LLC

  • Physical Therapist
  • Overland Park, KS
  • NPI 1598190209
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1731283200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1731283200000",
    "number": "1104640879",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1200 CORPORATE DR STE 400",
            "city": "HOOVER",
            "state": "AL",
            "postal_code": "352425424",
            "telephone_number": "423-238-7217",
            "fax_number": "423-238-3473"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "20320 I 30 # 190",
            "city": "BENTON",
            "state": "AR",
            "postal_code": "720198027",
            "telephone_number": "501-500-8188"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WAGNER",
        "first_name": "ETHAN",
        "middle_name": "JAMES",
        "credential": "DPT",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2024-11-11",
        "last_updated": "2024-11-11",
        "certification_date": "2024-11-11",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "AR",
            "license": "PT5585",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Brooke Virella, M.S.
• W. Grace Counseling PLLC
• Nissa Waddell, RECOVERY ASSISTANT
• Kristen Wade, CMP
• Larry Wade, CMP
• Stella Wagner, LPN
• Wal-Mart Stores, Inc.
• Deanna Walden
• Dorothy Waldroup, QBHP
• Walgreen Co

• All providers in Benton, AR
• Physical Therapist in Arkansas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 11, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.