Healthcare Provider Details

I. General information

NPI: 1184787962
Provider Name (Legal Business Name): RITA R WAGNER BSN, MS, RN, CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 01/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 WEST ARBOR DRIVE MC 8612
SAN DIEGO CA
92103-8612
US

IV. Provider business mailing address

300 W 55TH ST 3H
NEW YORK NY
10019-5151
US

V. Phone/Fax

Practice location:
  • Phone: 619-543-5350
  • Fax: 619-473-3014
Mailing address:
  • Phone: 209-480-0774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberCNMW1654
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberF001398-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: