Provider Demographics
NPI:1548747199
Name:WAGNER, NAOMI ELIZABETH (MS)
Entity Type:Individual
Prefix:
First Name:NAOMI
Middle Name:ELIZABETH
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 232410
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-2410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 W ARBOR DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-9000
Practice Address - Country:US
Practice Address - Phone:800-926-8273
Practice Address - Fax:888-539-8781
Is Sole Proprietor?:No
Enumeration Date:2018-07-26
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPGC134170300000X
CAGC001304170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS