Healthcare Provider Details

I. General information

NPI: 1053720490
Provider Name (Legal Business Name): REBECCA WAGNER MICHAELS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: REBECCA L WAGNER

II. Dates (important events)

Enumeration Date: 08/11/2014
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6535 NEMOURS PKWY
ORLANDO FL
32827-7884
US

IV. Provider business mailing address

10140 CENTURION PKWY N
JACKSONVILLE FL
32256-0532
US

V. Phone/Fax

Practice location:
  • Phone: 407-650-7000
  • Fax: 407-567-5924
Mailing address:
  • Phone: 904-697-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0010-11827
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9121186
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110006278
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: