Provider Demographics
NPI:1184787962
Name:WAGNER, RITA R (BSN, MS, RN, CNM)
Entity type:Individual
Prefix:
First Name:RITA
Middle Name:R
Last Name:WAGNER
Suffix:
Gender:F
Credentials:BSN, MS, RN, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W 55TH ST
Mailing Address - Street 2:3H
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-5151
Mailing Address - Country:US
Mailing Address - Phone:209-480-0774
Mailing Address - Fax:
Practice Address - Street 1:200 WEST ARBOR DRIVE
Practice Address - Street 2:MC 8612
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-8612
Practice Address - Country:US
Practice Address - Phone:619-543-5350
Practice Address - Fax:619-473-3014
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACNMW1654176B00000X
NYF001398-1176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife