Provider Demographics
NPI:1073190773
Name:WAGNER, MARINA ALYSSA (DO)
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:ALYSSA
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1648
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97440-1648
Mailing Address - Country:US
Mailing Address - Phone:541-242-4384
Mailing Address - Fax:
Practice Address - Street 1:2647 NE 33RD AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-3647
Practice Address - Country:US
Practice Address - Phone:503-288-0083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-27
Last Update Date:2025-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO218072207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine