Healthcare Provider Details

I. General information

NPI: 1346363751
Provider Name (Legal Business Name): MS. ANDREA THERESA WAGONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4367 MOWRY AVE
FREMONT CA
94538-1257
US

IV. Provider business mailing address

4367 MOWRY AVE
FREMONT CA
94538-1257
US

V. Phone/Fax

Practice location:
  • Phone: 510-794-6105
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: