Provider Demographics
NPI:1770649766
Name:WAGNER, GEORGE W JR (DC)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:W
Last Name:WAGNER
Suffix:JR
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 1:1330 COMMERCE ST.
Mailing Address - Street 2:SUITE B
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954
Mailing Address - Country:US
Mailing Address - Phone:707-773-2273
Mailing Address - Fax:707-773-1734
Practice Address - Street 1:1330 COMMERCE ST
Practice Address - Street 2:SUITE B
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-1496
Practice Address - Country:US
Practice Address - Phone:707-773-2273
Practice Address - Fax:707-773-1734
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC27302111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0273020Medicare ID - Type Unspecified
CAU82839Medicare UPIN