Healthcare Provider Details

I. General information

NPI: 1649603036
Provider Name (Legal Business Name): ERIC MATTHEW WAGONER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2013
Last Update Date: 06/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2139 E BEECHWOOD AVE
FRESNO CA
93720-0340
US

IV. Provider business mailing address

2139 E BEECHWOOD AVE
FRESNO CA
93720-0340
US

V. Phone/Fax

Practice location:
  • Phone: 559-322-6600
  • Fax:
Mailing address:
  • Phone: 209-402-1339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: