Healthcare Provider Details

I. General information

NPI: 1346433174
Provider Name (Legal Business Name): MARSHA WAGNER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2007
Last Update Date: 11/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

723 WALNUT DR
PASO ROBLES CA
93446-2315
US

IV. Provider business mailing address

723 WALNUT DR
PASO ROBLES CA
93446-2315
US

V. Phone/Fax

Practice location:
  • Phone: 805-237-3050
  • Fax: 805-237-3057
Mailing address:
  • Phone: 805-237-3050
  • Fax: 805-237-3057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberD234238
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License NumberD234238
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: