MEDICARE: JENNIFER WAGNER INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	PA9101701	FL

General Provider Information

NPI Number	:	1467846956
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JENNIFER WAGNER INC

Provider Business Mailing Address
First Line	:	20201 NE 21ST AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33179-2804
Country	:	US
Telephone Number	:	305-987-4443
Fax Number	:

Provider Business Practice Location Address
First Line	:	20201 NE 21ST AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33179-2804
Country	:	US
Telephone Number	:	305-987-4443
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JENNIFER WAGNER
Credential	:	PA
Telephone Number	:	305-987-4443

Provider Enumeration Date	:	03/24/2015
Last Update Date	:	03/24/2015

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