Provider Demographics
NPI:1770801359
Name:WAGNER, NICHOLAS R (ARNP)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:R
Last Name:WAGNER
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 N. ARNOLD RD.
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32413
Mailing Address - Country:US
Mailing Address - Phone:850-238-4100
Mailing Address - Fax:
Practice Address - Street 1:1002 N. ARNOLD RD.
Practice Address - Street 2:SUITE 101
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32413
Practice Address - Country:US
Practice Address - Phone:850-238-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-06
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9243050363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily