1063094183 NPI number — WOUND MASTERS MOBILE PHYSICIANS, PC

Table of content: DR. GREGORY ALAN WAGONER M.D. (NPI 1700965324)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063094183 NPI number — WOUND MASTERS MOBILE PHYSICIANS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WOUND MASTERS MOBILE PHYSICIANS, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063094183
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/13/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25044 PEACHLAND AVE STE 110
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWHALL
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91321-5730
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2325 E CAMELBACK RD
Provider Second Line Business Practice Location Address:
STE 400H
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85016-3422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-479-2111
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/27/2021

Additional Information

Authorized Official

Authorized Official Last Name:
NGAMFON
Authorized Official First Name:
WILLS
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
310-400-9942

Provider Taxonomy Codes

  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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