Basic Information
| Provider Information | |||||||||
| NPI: | 1467846956 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JENNIFER WAGNER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20201 NE 21ST AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331792804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3059874443 | ||||||||
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| Practice Location | |||||||||
| Address1: | 20201 NE 21ST AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331792804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3059874443 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2015 | ||||||||
| LastUpdateDate: | 03/24/2015 | ||||||||
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| AuthorizedOfficialLastName: | WAGNER | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3059874443 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA9101701 | FL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.