Healthcare Provider Details

I. General information

NPI: 1306877691
Provider Name (Legal Business Name): WILLIAM O. WAGNON DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 07/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1319 COLLEGE ST
WOODLAND CA
95695-4706
US

IV. Provider business mailing address

1319 COLLEGE ST
WOODLAND CA
95695-4706
US

V. Phone/Fax

Practice location:
  • Phone: 530-666-6662
  • Fax: 530-666-6643
Mailing address:
  • Phone: 530-666-6662
  • Fax: 530-666-6643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number14800
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: