# WAGNER GERVAIS

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- **Entity:** Individual
- **Status:** Active
- **Sole proprietor:** Yes

## Provider details

- **NPI number:** 1518596295
- **Gender:** Man

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207QA0000X | Adolescent Medicine (Family Medicine) Physician | 258-PA | PR | Yes |

## Other

- **Enumeration date:** 04/05/2020
- **Last updated:** 04/05/2020