Provider Demographics
NPI:1760467948
Name:WAGNER, PAULA (FNP)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4860 Y ST
Mailing Address - Street 2:SUITE 2200
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-2307
Mailing Address - Country:US
Mailing Address - Phone:916-734-8482
Mailing Address - Fax:916-734-8094
Practice Address - Street 1:4860 Y ST
Practice Address - Street 2:SUITE 2200
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2307
Practice Address - Country:US
Practice Address - Phone:916-734-8482
Practice Address - Fax:916-734-8094
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA83339363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ19781ZMedicaid
CAZZZ19781ZMedicaid
CAP22572Medicare UPIN