Provider Demographics
NPI:1912772336
Name:AMELIE WAGNER, M.D.
Entity Type:Organization
Organization Name:AMELIE WAGNER, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMELIE
Authorized Official - Middle Name:CORINNE
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-757-0730
Mailing Address - Street 1:500 E HAMILTON AVE # 1042
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-0210
Mailing Address - Country:US
Mailing Address - Phone:408-757-0730
Mailing Address - Fax:
Practice Address - Street 1:3425 RUE DU PARC
Practice Address - Street 2:
Practice Address - City:CANTON-DE-HATLEY
Practice Address - State:QUEBEC
Practice Address - Zip Code:J0B2C0
Practice Address - Country:CA
Practice Address - Phone:408-757-0730
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-15
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty