Provider Demographics
NPI:1750776605
Name:WAGNER, BRADLEY
Entity type:Individual
Prefix:
First Name:BRADLEY
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 1:2101 S TAMIAMI TRL
Mailing Address - Street 2:
Mailing Address - City:OSPREY
Mailing Address - State:FL
Mailing Address - Zip Code:34229-9668
Mailing Address - Country:US
Mailing Address - Phone:941-477-2101
Mailing Address - Fax:
Practice Address - Street 1:2101 S TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:OSPREY
Practice Address - State:FL
Practice Address - Zip Code:34229-9668
Practice Address - Country:US
Practice Address - Phone:941-477-2101
Practice Address - Fax:941-303-8188
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-30
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS3407237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist