Healthcare Provider Details

I. General information

NPI: 1083148936
Provider Name (Legal Business Name): SAMUEL WAGNER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2017
Last Update Date: 06/02/2022
Certification Date: 06/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 POTRERO AVE RM 1E21
SAN FRANCISCO CA
94110-3518
US

IV. Provider business mailing address

1001 POTRERO AVE RM 1E21
SAN FRANCISCO CA
94110-3518
US

V. Phone/Fax

Practice location:
  • Phone: 628-206-5753
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA169300
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: