Healthcare Provider Details

I. General information

NPI: 1205078706
Provider Name (Legal Business Name): ASHLEY C WAGNER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2009
Last Update Date: 11/27/2024
Certification Date: 11/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 REDSTONE AVE W
CRESTVIEW FL
32536-6433
US

IV. Provider business mailing address

350 REDSTONE AVE W
CRESTVIEW FL
32536-6433
US

V. Phone/Fax

Practice location:
  • Phone: 850-689-1740
  • Fax: 850-682-6652
Mailing address:
  • Phone: 850-689-1740
  • Fax: 850-682-6652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9105434
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: