Kimberly Thomas Wagner, PT

Primary specialty

Physical TherapistTaxonomy code 225100000X

License

PT17258 Issued in FL

Practice address

3801 E Highway 98
Port St Joe, FL 32456-5318

Phone

(850) 229-5752

NPI assigned

Jan 30, 2007

Last updated

Jan 25, 2012By the provider in NPPES

Sex

Female

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 FL

Enrollment records 1

Specialty

Physical Therapist in Private Practice

Education

Other, 1998

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Pro Vita Physical Therapy LLCGroup PAC ID 6901226976, 6 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

State licenses

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, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Pro Vita Physical Therapy LLC

  • Physical Therapy Clinic/Center
  • Crestview, FL
  • NPI 1790332351

  Physical Therapist

  Medicare reassignment Care Compare group NPD
• Pro Vita Physical Therapy LLC

  dba Pro Vita Physical Therapy - Shalimar

  • Physical Therapist
  • Fort Walton Beach, FL
  • NPI 1841944535
  NPD (past)

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

{
    "created_epoch": "1170115200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1327449600000",
    "number": "1518003995",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "517 8TH ST",
            "city": "PORT ST JOE",
            "state": "FL",
            "postal_code": "324561715",
            "telephone_number": "352-317-7180"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3801 E HIGHWAY 98",
            "city": "PORT ST JOE",
            "state": "FL",
            "postal_code": "324565318",
            "telephone_number": "850-229-5752"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WAGNER",
        "first_name": "KIMBERLY",
        "middle_name": "THOMAS",
        "name_prefix": "Mrs.",
        "credential": "PT",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2007-01-30",
        "last_updated": "2012-01-25",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "FL",
            "license": "PT17258",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Derek D Tracy, D.C.
• Lisa M Trautman, APRN PMHNP-BC, FNP-C
• Luis C Vazquez-Alvarado, MD
• Marni Liane Vedova
• Vincent M Ivers
• Regina C Washabaugh, RN
• David James Whitfield, MSPT, DPT
• Sheila E Whitfield
• Carolyn McCullagh Williams, PA-C
• Doris Evelyn Youngs, RN

• Physical Therapist in Port St Joe, FL
• Providers in Port St Joe, FL by specialty
• Physical Therapist in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 25, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.