Provider Demographics
NPI:1265071419
Name:WAGNER, ROBERT
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 S UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-2018
Mailing Address - Country:US
Mailing Address - Phone:954-262-1250
Mailing Address - Fax:
Practice Address - Street 1:3800 RESERVOIR RD NW # 2PHC
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20007-2113
Practice Address - Country:US
Practice Address - Phone:954-262-1250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-04
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA200001305363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant