Healthcare Provider Details

I. General information

NPI: 1124233184
Provider Name (Legal Business Name): PAMELA H.S. WAGNER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2007
Last Update Date: 01/09/2025
Certification Date: 01/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 CREEKSIDE DR STE 110
FOLSOM CA
95630-3491
US

IV. Provider business mailing address

1000 FOWLER WAY 2
PLACERVILLE CA
95667-5738
US

V. Phone/Fax

Practice location:
  • Phone: 916-649-1515
  • Fax: 916-649-1516
Mailing address:
  • Phone: 530-626-0058
  • Fax: 530-626-0092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberA101998
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: