Healthcare Provider Details

I. General information

NPI: 1205867892
Provider Name (Legal Business Name): ALESIA JOY WAGNER-LARGENT D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALESIA J WAGNER D.O.

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 11/19/2021
Certification Date: 11/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1119 E MONTE VISTA AVE
VACAVILLE CA
95688
US

IV. Provider business mailing address

1310 CLUB DR
VALLEJO CA
94592-1187
US

V. Phone/Fax

Practice location:
  • Phone: 707-469-4640
  • Fax:
Mailing address:
  • Phone: 707-638-5290
  • Fax: 707-638-5255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS0017549
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR3E50
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5121
License Number StateNV
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A8597
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: