Basic Information
| Provider Information | |||||||||
| NPI: | 1033303938 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7001A EAST PKWY | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958232501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9168755000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9333 TECH CENTER DR | ||||||||
| Address2: | SUITE 800 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958262583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9168755000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2007 | ||||||||
| LastUpdateDate: | 09/04/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | F282889 | CA | Y | Nursing Service Providers | Registered Nurse |
No ID Information.