Provider Demographics
NPI:1861125312
Name:WAGDA, DANIEL JOHN (PA-C)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:JOHN
Last Name:WAGDA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 EXCHANGE ST STE B7
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:GA
Mailing Address - Zip Code:31324-7646
Mailing Address - Country:US
Mailing Address - Phone:912-756-2273
Mailing Address - Fax:
Practice Address - Street 1:60 EXCHANGE ST STE B7
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:GA
Practice Address - Zip Code:31324-7646
Practice Address - Country:US
Practice Address - Phone:912-756-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-01
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028458363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant