Provider Demographics
NPI:1952621328
Name:SIERRA NEVADA PRIMARY CARE
Entity Type:Organization
Organization Name:SIERRA NEVADA PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-272-9788
Mailing Address - Street 1:PO BOX 459001
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-9101
Mailing Address - Country:US
Mailing Address - Phone:530-272-9788
Mailing Address - Fax:530-272-1056
Practice Address - Street 1:11400 PLEASANT VALLEY RD
Practice Address - Street 2:
Practice Address - City:PENN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95946-9001
Practice Address - Country:US
Practice Address - Phone:530-432-7023
Practice Address - Fax:530-432-7026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-08
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA371126363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty