Provider Demographics
NPI:1952743924
Name:WAGNER, KRISTIN (PA)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 W. EAU GALLIE BLVD.
Mailing Address - Street 2:SUITE 202C
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-3166
Mailing Address - Country:US
Mailing Address - Phone:321-728-2722
Mailing Address - Fax:321-435-3652
Practice Address - Street 1:2200 W. EAU GALLIE BLVD.
Practice Address - Street 2:SUITE 202C
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-3166
Practice Address - Country:US
Practice Address - Phone:321-728-2722
Practice Address - Fax:321-435-3652
Is Sole Proprietor?:No
Enumeration Date:2013-07-19
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106405363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant