Provider Demographics
NPI:1699719419
Name:SIERRA NEVADA PRIMARY CARE
Entity type:Organization
Organization Name:SIERRA NEVADA PRIMARY CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, BOARD OF DIRECTORS
Authorized Official - Prefix:MR
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:530-272-9791
Mailing Address - Street 1:PO BOX 459001
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-9101
Mailing Address - Country:US
Mailing Address - Phone:530-265-7833
Mailing Address - Fax:530-470-1821
Practice Address - Street 1:140 LITTON DR STE 110
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:530-272-9770
Practice Address - Fax:530-272-9796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A79401207Q00000X
CA20A7977207Q00000X
CAG55765207Q00000X
CAG13927207Q00000X
CAG61414208000000X
CAA71856208000000X
CAG23768208000000X
CAG35403208000000X
CAA26753208000000X
CAG34453208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA39118Medicare UPIN
CAH65229Medicare UPIN
CAF37879Medicare UPIN
CAH75406Medicare UPIN
CAZZZ18985ZMedicare ID - Type UnspecifiedPRACTICE ID NUMBER
CAH66067Medicare UPIN
CAA24950Medicare UPIN
CAA45931Medicare UPIN
CAA42062Medicare UPIN
CAA51763Medicare UPIN
CAE48092Medicare UPIN