| Doctor Name: | JUSTIN EDWARD WAGNON |
| NPI Number: | 1295112183 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | NP-C |
| License Number: | RN217684 |
| Business Practice Address: | 105 E 4th Ave Cordele, GA - 310153262 |
| Business Phone Number: | 2292739320 |
| Business Fax Number: | |
| Mailing Address: | 105 E 4th Ave, CORDELE |
| State: | GA |
| Postal Code: | 310153262 |
| Phone Number: | 2292739320 |
| Fax Number: | |
| NPI Enumeration Date: | 04/30/2015 |
| NPI Last Update Date: | 04/30/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LG0600X |
| License Number: | RN217684 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | GA |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Gerontology |
| Taxonomy Definition: | |