Provider Demographics
NPI:1609980093
Name:WAGNER, JENNIFER R (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:R
Other - Last Name:FEINBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:20201 NE 21ST AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33179-2804
Mailing Address - Country:US
Mailing Address - Phone:305-532-2411
Mailing Address - Fax:305-532-9793
Practice Address - Street 1:20201 NE 21ST AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33179-2804
Practice Address - Country:US
Practice Address - Phone:305-987-4443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101701363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLW57982Medicare UPIN
FLE6315Medicare PIN