Active NPI
Lisa Wagoner, P.T.A.
- Physical Therapy Assistant
- Medford, OR
National Provider Identifier
1508124199
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapy Assistant
- License
- 8785
- Practice address
- 400 Crater Lake Ave
Medford, OR 97504-6808 - Phone
- (541) 613-6505
- NPI assigned
- May 2, 2012
- 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 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapy Assistant | 225200000X | PTA-2842 | ID | |
| Physical Therapy Assistant | 225200000X | 8785 | OR | Primary |
Addresses
Primary practice location
400 Crater Lake Ave
Medford, OR 97504-6808
Mailing address
113 N Elm St
Canby, OR 97013-3519
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)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PTA-2842 | ID | MD | Physical Therapy Assistant |
| 8785 | OR | MD | Physical Therapy Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1335916800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1682899200000",
"number": "1508124199",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "113 N ELM ST",
"city": "CANBY",
"state": "OR",
"postal_code": "970133519"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "400 CRATER LAKE AVE",
"city": "MEDFORD",
"state": "OR",
"postal_code": "975046808",
"telephone_number": "541-613-6505"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WAGONER",
"first_name": "LISA",
"credential": "P.T.A.",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2012-05-02",
"last_updated": "2023-05-01",
"certification_date": "2023-05-01",
"status": "A"
},
"taxonomies": [
{
"code": "225200000X",
"taxonomy_group": "",
"desc": "Physical Therapy Assistant",
"state": "ID",
"license": "PTA-2842",
"primary": false
},
{
"code": "225200000X",
"taxonomy_group": "",
"desc": "Physical Therapy Assistant",
"state": "OR",
"license": "8785",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Medford, OR
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 1, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.