Provider Demographics
NPI:1861058315
Name:WAGNER, ANDREW JOHN (AUD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:JOHN
Last Name:WAGNER
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3170 N FEDERAL HWY STE 115
Mailing Address - Street 2:
Mailing Address - City:LIGHTHOUSE POINT
Mailing Address - State:FL
Mailing Address - Zip Code:33064-6721
Mailing Address - Country:US
Mailing Address - Phone:954-943-9020
Mailing Address - Fax:
Practice Address - Street 1:3170 N FEDERAL HWY STE 115
Practice Address - Street 2:
Practice Address - City:LIGHTHOUSE POINT
Practice Address - State:FL
Practice Address - Zip Code:33064-6786
Practice Address - Country:US
Practice Address - Phone:954-943-9020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY2262231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist