Individual
MARK ANDREW WAGNER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
36680 CLOVERLEAF AVE, MADERA, CA 93636-8519
(209) 489-9347
(209) 720-0107
Mailing address
4301 NORTHSTAR WAY, MODESTO, CA 95356-9262
(209) 342-2300
(209) 524-4240
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
20A5259
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00AX52590
—
CA
01
—
020A52590
BLUE SHIELD
CA
Enumeration date
11/02/2005
Last updated
06/24/2024
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