Provider Demographics
NPI:1770122996
Name:WAGENKNECHT, VICTORIA (PA-C)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:WAGENKNECHT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:
Other - Last Name:KERN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-1105
Mailing Address - Fax:239-343-1106
Practice Address - Street 1:13340 METRO PKWY STE 400
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-4818
Practice Address - Country:US
Practice Address - Phone:239-343-1105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-06
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105172200Medicaid