Basic Information
| Provider Information | |||||||||
| NPI: | 1194753681 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGMAN | ||||||||
| FirstName: | FELICIA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 367 S. GULPH RD | ||||||||
| Address2: | ATTN: IPM CREDENTIALING | ||||||||
| City: | KING OF PRUSSIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194063121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417822800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8340 LAKEWOOD RANCH BLVD STE 210 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD RANCH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417822800 | ||||||||
| FaxNumber: | 9417822513 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 06/17/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | L3174 | TX | N | Other Service Providers | Specialist | 207V00000X | ME130060 | FL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 202059124 | 01 | TX | TAX ID | OTHER |