Provider Demographics
NPI:1427072008
Name:SIERRA NEVADA PRIMARY CARE PHYSICIANS A MEDICAL CORPORATION
Entity type:Organization
Organization Name:SIERRA NEVADA PRIMARY CARE PHYSICIANS A MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, BOARD OF DIRECTORS
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-477-4016
Mailing Address - Street 1:P.O BOX 459001
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-9109
Mailing Address - Country:US
Mailing Address - Phone:530-477-4016
Mailing Address - Fax:530-477-4018
Practice Address - Street 1:140 LITTON DR STE 100
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5078
Practice Address - Country:US
Practice Address - Phone:530-477-4016
Practice Address - Fax:530-477-4018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7940207Q00000X
CAC52481207Q00000X
CA1730163791363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ18985ZMedicare PIN