Provider Demographics
NPI:1871016295
Name:WAGNER, BRYAN J (OT, ATC, LAT)
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:J
Last Name:WAGNER
Suffix:
Gender:M
Credentials:OT, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 RIVERSIDE AVE
Mailing Address - Street 2:190
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4500 SAN PABLO RD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-1865
Practice Address - Country:US
Practice Address - Phone:904-953-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-18
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL48392255A2300X
FLOT24282225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer