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General NPI Number Information
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NPI Number | 1366225906
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Entity Type | Individual
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Provider Name | AUDREY WAGDY
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Gender | Female
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Dates
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Enumeration Date | 08/16/2023
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Last Update Date | 10/03/2024
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Provider Practice Location Address
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Address Line | 1151 E WALNUT ST
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City | ONTARIO
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State | CA
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Zip | 91761-6155
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Country | US
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Telephone | 909-467-1425
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Fax | 909-773-0920
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Provider Business Mailing Address
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Address Line | 1151 E WALNUT ST
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City | ONTARIO
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State | CA
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Zip | 91761-6155
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Country | US
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Telephone | 909-467-1425
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Fax | 909-773-0920
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State |
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