Healthcare Provider Details

I. General information

NPI: 1164601936
Provider Name (Legal Business Name): LORI B WAGNER D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2007
Last Update Date: 10/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1502 E FOWLER AVE
TAMPA FL
33612-5416
US

IV. Provider business mailing address

3905 APPLETREE DR
VALRICO FL
33594-4316
US

V. Phone/Fax

Practice location:
  • Phone: 813-866-0950
  • Fax: 813-866-0929
Mailing address:
  • Phone: 813-689-6051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS6338
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: