Provider Demographics
NPI:1215351697
Name:WAGNER, BRUCE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 CANAL POINT RD
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-4562
Mailing Address - Country:US
Mailing Address - Phone:407-832-2955
Mailing Address - Fax:407-339-2955
Practice Address - Street 1:1410 CANAL POINT RD
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-4562
Practice Address - Country:US
Practice Address - Phone:407-832-2955
Practice Address - Fax:407-339-2955
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-06
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107368363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical