Provider Demographics
NPI:1205809365
Name:WAGNER, SANGEETA S (DO)
Entity type:Individual
Prefix:
First Name:SANGEETA
Middle Name:S
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SANGEETA
Other - Middle Name:
Other - Last Name:SHARMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 740433
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-0433
Mailing Address - Country:US
Mailing Address - Phone:775-352-5335
Mailing Address - Fax:775-352-5334
Practice Address - Street 1:5265 VISTA BLVD BLDG B
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89436-0836
Practice Address - Country:US
Practice Address - Phone:775-352-5335
Practice Address - Fax:775-352-5334
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1038207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
11426504OtherCAQH
NV1205809365Medicaid
11426504OtherCAQH
NVP00079508OtherRAILROAD MEDICARE
11426504OtherCAQH
NVV38977Medicare PIN
NVCR854ZMedicare PIN