Provider Demographics
NPI:1457544983
Name:WAGNER, SUSAN KATALI (PA-C)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:KATALI
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:KATALI
Other - Last Name:WAGABAZA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:26610 KALMIA AVE
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-1727
Mailing Address - Country:US
Mailing Address - Phone:951-601-3814
Mailing Address - Fax:
Practice Address - Street 1:6926 BROCKTON AVE
Practice Address - Street 2:STE 9
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-3800
Practice Address - Country:US
Practice Address - Phone:951-788-0370
Practice Address - Fax:951-788-0390
Is Sole Proprietor?:No
Enumeration Date:2007-08-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARCP199992278G1100X
CAPA16194363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No2278G1100XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedGeneral Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA16194OtherSTATE
GA1034312OtherNCCPA
GA1034312OtherNCCPA
GA1034312OtherNCCPA