Provider Demographics
NPI:1205867892
Name:WAGNER-LARGENT, ALESIA JOY (DO)
Entity type:Individual
Prefix:DR
First Name:ALESIA
Middle Name:JOY
Last Name:WAGNER-LARGENT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:ALESIA
Other - Middle Name:J
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:1310 CLUB DR
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94592-1187
Mailing Address - Country:US
Mailing Address - Phone:707-638-5290
Mailing Address - Fax:707-638-5255
Practice Address - Street 1:1119 E MONTE VISTA AVE
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688
Practice Address - Country:US
Practice Address - Phone:707-469-4640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0017549207Q00000X
MOR3E50207Q00000X
NV5121207Q00000X
CA20A8597207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine