Basic Information
| Provider Information | |||||||||
| NPI: | 1477157873 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | GORDON | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RPH | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1350 LEE BLVD | ||||||||
| Address2: | |||||||||
| City: | LEHIGH ACRES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339364846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393692163 | ||||||||
| FaxNumber: | 2393687497 | ||||||||
| Practice Location | |||||||||
| Address1: | 1350 LEE BLVD | ||||||||
| Address2: | |||||||||
| City: | LEHIGH ACRES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339364846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393692163 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2020 | ||||||||
| LastUpdateDate: | 11/25/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | PS0027995 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 105903300 | 05 | FL | MEDICAID |