Provider Demographics
NPI:1578675666
Name:WAGNER, BARBARA ANN (PA)
Entity type:Individual
Prefix:
First Name:BARBARA
Middle Name:ANN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5040
Mailing Address - Street 2:
Mailing Address - City:OROVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95966
Mailing Address - Country:US
Mailing Address - Phone:530-532-8584
Mailing Address - Fax:530-532-8433
Practice Address - Street 1:2809 OLIVE HIGHWAY
Practice Address - Street 2:SUITE #350
Practice Address - City:OROVILLE
Practice Address - State:CA
Practice Address - Zip Code:95966
Practice Address - Country:US
Practice Address - Phone:530-532-8654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17371363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q21085Medicare UPIN
CA0PA173710Medicare ID - Type Unspecified