MEDICARE: JENNIFER R WAGNER PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA9101701	FL

General Provider Information

NPI Number	:	1609980093
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER R WAGNER PA-C

Provider Business Mailing Address
First Line	:	20201 NE 21ST AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33179-2804
Country	:	US
Telephone Number	:	305-532-2411
Fax Number	:	305-532-9793

Provider Business Practice Location Address
First Line	:	20201 NE 21ST AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33179-2804
Country	:	US
Telephone Number	:	305-987-4443
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2006
Last Update Date	:	12/08/2014

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Directions to “ JENNIFER R WAGNER PA-C” Practice Location

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