Provider Demographics
NPI:1598720229
Name:WAGNER, JOYCE LYNN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JOYCE
Middle Name:LYNN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1545 9TH ST SW
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32962-4312
Mailing Address - Country:US
Mailing Address - Phone:772-257-8224
Mailing Address - Fax:772-213-3157
Practice Address - Street 1:1553 US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960
Practice Address - Country:US
Practice Address - Phone:772-257-8224
Practice Address - Fax:772-213-3157
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102320363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9102320OtherSTATE LICENSE