Individual
RYAN COLT WAGONER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
3515 E FLETCHER AVE, MDC 14, TAMPA, FL 33613-4702
(813) 974-8900
Mailing address
PO BOX 917770, ORLANDO, FL 32891-0001
(813) 974-2201
(813) 974-4325
Taxonomy
Speciality
Code
Description
License number
State
2084F0202X
Forensic Psychiatry Physician
A124075
CA
2084P0800X
Psychiatry Physician
71582
GA
2084P0800X
Psychiatry Physician
Primary
ME119037
FL
390200000X
Student in an Organized Health Care Education/Training Program
MT194511
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
015294500
—
FL
01
—
1510A
BLUE CROSS BLUE SHIELD
FL
Enumeration date
07/21/2009
Last updated
03/31/2021
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