Healthcare Provider Details

I. General information

NPI: 1518063916
Provider Name (Legal Business Name): PAUL BROOKS WAGNER C.C.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1836 HARBOR CV
MODESTO CA
95355-1856
US

IV. Provider business mailing address

1836 HARBOR CV
MODESTO CA
95355-1856
US

V. Phone/Fax

Practice location:
  • Phone: 209-484-8516
  • Fax: 209-576-3613
Mailing address:
  • Phone: 209-484-8516
  • Fax: 209-576-3613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246XC2903X
TaxonomyVascular Specialist/Technologist Cardiovascular
License Number890191-0970
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: