Provider Demographics
NPI:1013081496
Name:WAGILLA, OSMAN
Entity type:Individual
Prefix:
First Name:OSMAN
Middle Name:
Last Name:WAGILLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 W LEGION RD
Mailing Address - Street 2:
Mailing Address - City:BRAWLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92227-7780
Mailing Address - Country:US
Mailing Address - Phone:760-351-3333
Mailing Address - Fax:
Practice Address - Street 1:2100 POWELL ST
Practice Address - Street 2:SUITE 900
Practice Address - City:EMERYVILLE
Practice Address - State:CA
Practice Address - Zip Code:94608-1826
Practice Address - Country:US
Practice Address - Phone:510-350-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18417363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPA18417AMedicare PIN