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General NPI Number Information
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NPI Number | 1306051362
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Entity Type | Individual
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Provider Name | JUSTIN B WAGNER M.D.
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Gender | Male
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Dates
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Enumeration Date | 05/13/2007
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Last Update Date | 06/30/2016
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Provider Practice Location Address
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Address Line | 1650 CREEKSIDE DR
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City | FOLSOM
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State | CA
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Zip | 95630-3400
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Country | US
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Telephone | 916-983-7470
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Fax |
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Provider Business Mailing Address
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Address Line | 2100 POWELL ST STE 900
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City | EMERYVILLE
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State | CA
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Zip | 94608-1844
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Country | US
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Telephone | 909-499-3611
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | A101997
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License Number State | CA
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