Provider Demographics
NPI:1912194366
Name:WAGNER, MICHAEL JACOB (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JACOB
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 WILLOW RD
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-2616
Mailing Address - Country:US
Mailing Address - Phone:650-330-1660
Mailing Address - Fax:
Practice Address - Street 1:300 PASTEUR DR
Practice Address - Street 2:STANFORD UNIVERSITY HOSPITAL
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305
Practice Address - Country:US
Practice Address - Phone:650-736-0289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-01
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA92317207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology