Provider Demographics
NPI:1700105285
Name:WAGNER, SHEILA D (ND, PT, CNS)
Entity Type:Individual
Prefix:
First Name:SHEILA
Middle Name:D
Last Name:WAGNER
Suffix:
Gender:F
Credentials:ND, PT, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 VIA BELARDO APT 6
Mailing Address - Street 2:
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904-2272
Mailing Address - Country:US
Mailing Address - Phone:415-778-6008
Mailing Address - Fax:
Practice Address - Street 1:1100 LARKSPUR LANDING CIR STE 255
Practice Address - Street 2:
Practice Address - City:LARKSPUR
Practice Address - State:CA
Practice Address - Zip Code:94939-1816
Practice Address - Country:US
Practice Address - Phone:415-945-3213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-24
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT100922251X0800X
CACN00885133NN1002X
CAND1013172P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172P00000XOther Service ProvidersNaprapathGroup - Multi-Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty