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General NPI Number Information
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NPI Number | 1518063916
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Entity Type | Individual
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Provider Name | PAUL BROOKS WAGNER C.C.P.
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Gender | Male
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Dates
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Enumeration Date | 09/15/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1836 HARBOR CV
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City | MODESTO
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State | CA
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Zip | 95355-1856
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Country | US
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Telephone | 209-484-8516
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Fax | 209-576-3613
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Provider Business Mailing Address
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Address Line | 1836 HARBOR CV
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City | MODESTO
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State | CA
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Zip | 95355-1856
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Country | US
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Telephone | 209-484-8516
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Fax | 209-576-3613
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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 | 246XC2903X
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Taxonomy Name | Vascular Specialist/Technologist Cardiovascular
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License Number | 890191-0970
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License Number State | MS
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