Healthcare Provider Details

I. General information

NPI: 1518596295
Provider Name (Legal Business Name): WAGNER GERVAIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2020
Last Update Date: 04/05/2020
Certification Date: 04/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 CALLE LAS LOMAS
SAN JUAN PR
00926-5527
US

IV. Provider business mailing address

151 CALLE LAS LOMAS
SAN JUAN PR
00926-5527
US

V. Phone/Fax

Practice location:
  • Phone: 956-578-6712
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number258-PA
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: