Provider Demographics
NPI:1891188983
Name:WAGEMANN, DOUGLAS II (NP)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:WAGEMANN
Suffix:II
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32392 COAST HWY STE 250
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-6776
Mailing Address - Country:US
Mailing Address - Phone:949-499-2265
Mailing Address - Fax:
Practice Address - Street 1:32392 COAST HWY STE 250
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-6776
Practice Address - Country:US
Practice Address - Phone:949-499-2265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-12
Last Update Date:2020-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95055166163W00000X
CA95011040363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse