Healthcare Provider Details

I. General information

NPI: 1619557204
Provider Name (Legal Business Name): SAMANTHA KAY WAGNER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2021
Last Update Date: 03/09/2026
Certification Date: 03/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 PIONEER LN STE B
BISHOP CA
93514-2517
US

IV. Provider business mailing address

150 PIONEER LN
BISHOP CA
93514-2556
US

V. Phone/Fax

Practice location:
  • Phone: 760-873-2623
  • Fax: 760-873-2626
Mailing address:
  • Phone: 760-873-5811
  • Fax: 760-872-5843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA195936
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: