Provider Demographics
NPI:1235145608
Name:SIERRA NEVADA PRIMARY CARE
Entity Type:Organization
Organization Name:SIERRA NEVADA PRIMARY CARE
Other - Org Name:SIERRA CARE PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT, BOARD OF DIRECTORS
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-272-9780
Mailing Address - Street 1:P.O. BOX 459001
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-9109
Mailing Address - Country:US
Mailing Address - Phone:530-477-4016
Mailing Address - Fax:530-477-4018
Practice Address - Street 1:140 LITTON DR STE 100
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5078
Practice Address - Country:US
Practice Address - Phone:530-272-9780
Practice Address - Fax:530-272-0156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG35403208000000X
CAG237680208000000X
CAA26753208000000X
CAG61414208000000X
CAA71856208000000X
CAG34453208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ18985ZMedicare ID - Type UnspecifiedPROVIDER ID NUMBER