Provider Demographics
NPI:1952531204
Name:WAGONER, RYAN COLT (MD)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:COLT
Last Name:WAGONER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:813-974-2201
Mailing Address - Fax:813-974-4325
Practice Address - Street 1:3515 E FLETCHER AVE
Practice Address - Street 2:MDC 14
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-4702
Practice Address - Country:US
Practice Address - Phone:813-974-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-21
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1240752084F0202X
GA715822084P0800X
PAMT194511390200000X
FLME1190372084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015294500Medicaid
FL1510AOtherBLUE CROSS BLUE SHIELD
FLIG859ZMedicare PIN
FL015294500Medicaid