Basic Information
| Provider Information | |||||||||
| NPI: | 1124233184 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | H.S. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 FOWLER WAY 2 | ||||||||
| Address2: | |||||||||
| City: | PLACERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956675738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306260058 | ||||||||
| FaxNumber: | 5306260092 | ||||||||
| Practice Location | |||||||||
| Address1: | 11234 ANDERSON ST | ||||||||
| Address2: | |||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923542804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095588131 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2007 | ||||||||
| LastUpdateDate: | 07/31/2015 | ||||||||
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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 | 207W00000X | A101998 | CA | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.