Individual
MICHAEL JUSTIN WAGONER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
5426 BEAUMONT CENTER BLVD STE 350, TAMPA, FL 33634-5235
(813) 286-0033
(813) 282-1806
Mailing address
PO BOX 748817, ATLANTA, GA 30374-8817
(813) 286-0333
(813) 282-1806
Taxonomy
Speciality
Code
Description
License number
State
207ZP0102X
Anatomic Pathology & Clinical Pathology Physician
Primary
ME103487
FL
390200000X
Student in an Organized Health Care Education/Training Program
TRN8871
FL
Other
Enumeration date
10/26/2007
Last updated
06/22/2023
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