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Individual

LUKE ANDREW WAGNER

Active
Sole proprietor
No

Provider details

NPI number
Gender
Man
Credential
SOIDC

Contact information

Practice address
917 3RD ST, CORONADO, CA 92118-1313
(305) 793-4777
Mailing address
917 3RD ST, CORONADO, CA 92118-1313
(305) 793-4777

Taxonomy

Speciality
Code
Description
License number
State
1710I1002X
Independent Duty Corpsman
Primary

Other

Enumeration date
07/14/2021
Last updated
07/14/2021
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