Provider Demographics
NPI:1598990798
Name:WAGER, CARRIE I (CMT)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:I
Last Name:WAGER
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 W CASTLE ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-4413
Mailing Address - Country:US
Mailing Address - Phone:209-462-1302
Mailing Address - Fax:
Practice Address - Street 1:1955 LUCILE AVE STE E
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95209-4703
Practice Address - Country:US
Practice Address - Phone:209-462-1302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-18
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMB-0600019175L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175L00000XOther Service ProvidersHomeopath