Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | E1749 | CA |
Y | 222Z00000X | Podiatrist | E1749 | CA |
NPI | 1053430322 |
---|---|
Provider Name | Stephen Clark Wagers |
First Address | San Diego, CA 92126-4827 |
Second Address | San Diego, CA 92126-4827 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/03/2007 |
Last Update Date | 08/07/2007 |