Healthcare Provider Details

I. General information

NPI: 1285722819
Provider Name (Legal Business Name): ANDREW STEPHEN WAGNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 04/09/2025
Certification Date: 04/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 MARK WEST SPRINGS RD
SANTA ROSA CA
95403-1436
US

IV. Provider business mailing address

30 MARK WEST SPRINGS RD
SANTA ROSA CA
95403-1436
US

V. Phone/Fax

Practice location:
  • Phone: 707-576-4000
  • Fax: 707-827-6327
Mailing address:
  • Phone: 707-235-6809
  • Fax: 707-827-6327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License NumberG50907
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: