Provider Demographics
NPI:1285412916
Name:WAGNER, BRIDGET (RDN)
Entity type:Individual
Prefix:
First Name:BRIDGET
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6130 N LA CHOLLA BLVD STE 250
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85741-3698
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6130 N LA CHOLLA BLVD STE 250
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741-3698
Practice Address - Country:US
Practice Address - Phone:520-219-8690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-14
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA86293310133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered