Provider Demographics
NPI:1871210021
Name:WAGNER, RYAN (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1138 LA GRANDE AVE
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-2168
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20601 W PAOLI LN
Practice Address - Street 2:
Practice Address - City:WEIMAR
Practice Address - State:CA
Practice Address - Zip Code:95736
Practice Address - Country:US
Practice Address - Phone:530-637-4025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-27
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant