Provider Demographics
NPI:1306877691
Name:WAGNON, WILLIAM O (DC)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:O
Last Name:WAGNON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1319 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-4706
Mailing Address - Country:US
Mailing Address - Phone:530-666-6662
Mailing Address - Fax:530-666-6643
Practice Address - Street 1:1319 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-4706
Practice Address - Country:US
Practice Address - Phone:530-666-6662
Practice Address - Fax:530-666-6643
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14800111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician