Healthcare Provider Details

I. General information

NPI: 1477361699
Provider Name (Legal Business Name): WAGNER ISRAEL CILIO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2024
Last Update Date: 12/19/2024
Certification Date: 12/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 CANDELARIA RD NE STE B
ALBUQUERQUE NM
87107-1965
US

IV. Provider business mailing address

3301 CANDELARIA RD NE STE B
ALBUQUERQUE NM
87107-1965
US

V. Phone/Fax

Practice location:
  • Phone: 505-273-6300
  • Fax:
Mailing address:
  • Phone: 505-273-6300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-20240743
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: