Provider Demographics
NPI:1932350253
Name:WAGNON, ERIC DONALD (DC)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:DONALD
Last Name:WAGNON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4441 GRANITE DR STE 102
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677-2131
Mailing Address - Country:US
Mailing Address - Phone:916-625-0208
Mailing Address - Fax:916-925-0209
Practice Address - Street 1:4441 GRANITE DR STE 102
Practice Address - Street 2:
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95677-2131
Practice Address - Country:US
Practice Address - Phone:916-625-0208
Practice Address - Fax:916-925-0209
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-06
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30897111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor