MEDICARE: MR. PAUL BROOKS WAGNER C.C.P.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246XC2903X	Vascular Specialist/Technologist Cardiovascular	890191-0970	MS

General Provider Information

NPI Number	:	1518063916
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PAUL BROOKS WAGNER C.C.P.

Provider Business Mailing Address
First Line	:	1836 HARBOR CV
Second Line	:
City	:	MODESTO
State	:	CA
Zip	:	95355-1856
Country	:	US
Telephone Number	:	209-484-8516
Fax Number	:	209-576-3613

Provider Business Practice Location Address
First Line	:	1836 HARBOR CV
Second Line	:
City	:	MODESTO
State	:	CA
Zip	:	95355-1856
Country	:	US
Telephone Number	:	209-484-8516
Fax Number	:	209-576-3613

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/15/2006
Last Update Date	:	07/08/2007

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