Provider Demographics
NPI:1326033614
Name:WAGNER, STEVEN DANIEL (DO)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:DANIEL
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 MISSION RANCH BLVD
Mailing Address - Street 2:STE 10
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-2186
Mailing Address - Country:US
Mailing Address - Phone:530-894-0500
Mailing Address - Fax:530-345-2532
Practice Address - Street 1:114 MISSION RANCH BLVD
Practice Address - Street 2:STE 10
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-2186
Practice Address - Country:US
Practice Address - Phone:530-894-0500
Practice Address - Fax:530-345-2532
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA020A53980207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX53980Medicaid
CA00AX53980Medicaid
D16222Medicare UPIN