Active NPI
Kelli Jo Wagner, PT
- Physical Therapist
- Fort Collins, CO
National Provider Identifier
1225209653
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapist
- License
- PTL.0007418
- Practice address
- 2500 E Prospect Rd
Fort Collins, CO 80525-9718 - Phone
- (970) 493-0112
- NPI assigned
- Mar 13, 2008
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapist | 225100000X | PTL.0007418 | CO | Primary |
Addresses
Primary practice location
2500 E Prospect Rd
Fort Collins, CO 80525-9718
Mailing address
2500 E Prospect Rd
Fort Collins, CO 80525-9718
Phone (970) 493-0112
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 56634315 | Medicaid | CO |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PTL.0007418 | CO | MD | Physical Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1205366400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1413244800000",
"number": "1225209653",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2500 E PROSPECT RD",
"city": "FORT COLLINS",
"state": "CO",
"postal_code": "805259718",
"telephone_number": "970-493-0112"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2500 E PROSPECT RD",
"city": "FORT COLLINS",
"state": "CO",
"postal_code": "805259718",
"telephone_number": "970-493-0112"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WAGNER",
"first_name": "KELLI",
"middle_name": "JO",
"credential": "PT",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2008-03-13",
"last_updated": "2014-10-14",
"status": "A"
},
"taxonomies": [
{
"code": "225100000X",
"taxonomy_group": "",
"desc": "Physical Therapist",
"state": "CO",
"license": "PTL.0007418",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "56634315",
"state": "CO"
}
],
"endpoints": [],
"other_names": []
}Other providers in Fort Collins, CO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 14, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.