Provider Demographics
NPI:1679876817
Name:WAGNAC, JUDE A (DPT, ATC/L)
Entity Type:Individual
Prefix:MR
First Name:JUDE
Middle Name:A
Last Name:WAGNAC
Suffix:
Gender:M
Credentials:DPT, ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7353 NW 174TH TER APT 101
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-1135
Mailing Address - Country:US
Mailing Address - Phone:786-512-7783
Mailing Address - Fax:
Practice Address - Street 1:2950 CLEVELAND CLINIC BLVD
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33331-3609
Practice Address - Country:US
Practice Address - Phone:954-659-5370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-09
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 29266225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist