Healthcare Provider Details

I. General information

NPI: 1447200647
Provider Name (Legal Business Name): MICHEL RANDOLPH PETER WAGNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4619 LITTLE RD
NEW PORT RICHEY FL
34655-1329
US

IV. Provider business mailing address

3820 NORTHDALE BLVD STE 201
TAMPA FL
33624-1893
US

V. Phone/Fax

Practice location:
  • Phone: 800-991-6117
  • Fax: 888-812-8191
Mailing address:
  • Phone: 800-991-6117
  • Fax: 888-812-8191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME80662
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD066014L
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberMD066014L
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberMD066014L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: