Provider Demographics
NPI:1205078706
Name:WAGNER, ASHLEY C (PA)
Entity type:Individual
Prefix:MRS
First Name:ASHLEY
Middle Name:C
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:350 REDSTONE AVE W
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-6433
Mailing Address - Country:US
Mailing Address - Phone:850-689-1740
Mailing Address - Fax:850-682-6652
Practice Address - Street 1:350 REDSTONE AVE W
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-6433
Practice Address - Country:US
Practice Address - Phone:850-689-1740
Practice Address - Fax:850-682-6652
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-30
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105434363AM0700X
FLPA-9105434363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical