MEDICARE: RITA R WAGNER BSN, MS, RN, CNM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	176B00000X	Midwife	CNMW1654	CA
2	176B00000X	Midwife	F001398-1	NY

General Provider Information

NPI Number	:	1184787962
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RITA R WAGNER BSN, MS, RN, CNM

Provider Business Mailing Address
First Line	:	300 W 55TH ST
Second Line	:	3H
City	:	NEW YORK
State	:	NY
Zip	:	10019-5151
Country	:	US
Telephone Number	:	209-480-0774
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 WEST ARBOR DRIVE
Second Line	:	MC 8612
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-8612
Country	:	US
Telephone Number	:	619-543-5350
Fax Number	:	619-473-3014

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/19/2006
Last Update Date	:	01/25/2013

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