Provider Demographics
NPI:1427709492
Name:WAGNER, KYLE (DPT)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:WAGNER
Suffix:
Gender:
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10261 INNOVATION WAY
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-8172
Mailing Address - Country:US
Mailing Address - Phone:900-853-1030
Mailing Address - Fax:
Practice Address - Street 1:10261 INNOVATION WAY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-8172
Practice Address - Country:US
Practice Address - Phone:904-853-1030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-12
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT38044208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation