Provider Demographics
NPI:1386038636
Name:WAGNER, KEVIN (HAS, BC-HIS)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:HAS, BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3534 CLARK RD
Mailing Address - Street 2:#132
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34231-8408
Mailing Address - Country:US
Mailing Address - Phone:941-922-6028
Mailing Address - Fax:
Practice Address - Street 1:3534 CLARK RD
Practice Address - Street 2:#132
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34231-8408
Practice Address - Country:US
Practice Address - Phone:941-922-6028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-25
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS2789237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist