Provider Demographics
NPI:1528510930
Name:WAGNER, CHASE (NP-C)
Entity type:Individual
Prefix:
First Name:CHASE
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15611 POMERADO RD
Mailing Address - Street 2:FIFTH FLOOR
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-2437
Mailing Address - Country:US
Mailing Address - Phone:858-673-2574
Mailing Address - Fax:858-618-1523
Practice Address - Street 1:1955 CITRACADO PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92029-4110
Practice Address - Country:US
Practice Address - Phone:760-743-0546
Practice Address - Fax:760-743-8005
Is Sole Proprietor?:No
Enumeration Date:2016-11-01
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95004029363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner