Basic Information
| Provider Information | |||||||||
| NPI: | 1366885501 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | BRENT | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 72605 HIGHWAY 111 | ||||||||
| Address2: | |||||||||
| City: | PALM DESERT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922603392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604040135 | ||||||||
| FaxNumber: | 7605372948 | ||||||||
| Practice Location | |||||||||
| Address1: | 72605 HIGHWAY 111 | ||||||||
| Address2: | |||||||||
| City: | PALM DESERT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922603392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604040135 | ||||||||
| FaxNumber: | 7605372948 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2013 | ||||||||
| LastUpdateDate: | 04/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 143208 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.