Provider Demographics
NPI:1013095900
Name:WAGNER, MICHAEL V (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:V
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 1:3 HAZELWOOD DR
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-4306
Mailing Address - Country:US
Mailing Address - Phone:707-724-4719
Mailing Address - Fax:
Practice Address - Street 1:1000 TRANCAS ST
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-2906
Practice Address - Country:US
Practice Address - Phone:707-252-4411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG52985207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G529850Medicaid
00G529850Medicare ID - Type Unspecified
CA00G529850Medicaid