Provider Demographics
NPI:1376577270
Name:WAGNER, VERNON PAUL (MD)
Entity type:Individual
Prefix:
First Name:VERNON
Middle Name:PAUL
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 1:5500 MING AVE
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93309-4689
Mailing Address - Country:US
Mailing Address - Phone:661-836-2226
Mailing Address - Fax:
Practice Address - Street 1:5500 MING AVE
Practice Address - Street 2:SUITE 170
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93309-4689
Practice Address - Country:US
Practice Address - Phone:661-836-2226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACAG12163207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACAG12163OtherBLUE CROSS
CA00G121630Medicare ID - Type Unspecified