Provider Demographics
NPI:1598969545
Name:WAGNER, JAMES WILLIAM (DC)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:WILLIAM
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9574 MURRAY DR
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942
Mailing Address - Country:US
Mailing Address - Phone:619-414-1602
Mailing Address - Fax:619-414-1602
Practice Address - Street 1:9574 MURRAY DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942
Practice Address - Country:US
Practice Address - Phone:619-414-1602
Practice Address - Fax:619-414-1602
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA24956111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor