Healthcare Provider Details

I. General information

NPI: 1386038636
Provider Name (Legal Business Name): KEVIN WAGNER HAS, BC-HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2015
Last Update Date: 03/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3534 CLARK RD #132
SARASOTA FL
34231-8408
US

IV. Provider business mailing address

3534 CLARK RD #132
SARASOTA FL
34231-8408
US

V. Phone/Fax

Practice location:
  • Phone: 941-922-6028
  • Fax:
Mailing address:
  • Phone: 941-922-6028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberAS2789
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: