Provider Demographics
NPI:1235457359
Name:WAGNER, AMANDA ELLEN (MD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:ELLEN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MD
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 577
Mailing Address - Street 2:
Mailing Address - City:STAYTON
Mailing Address - State:OR
Mailing Address - Zip Code:97383-0577
Mailing Address - Country:US
Mailing Address - Phone:503-769-2175
Mailing Address - Fax:503-769-3472
Practice Address - Street 1:1373 N 10TH AVE
Practice Address - Street 2:
Practice Address - City:STAYTON
Practice Address - State:OR
Practice Address - Zip Code:97383-2037
Practice Address - Country:US
Practice Address - Phone:503-769-9522
Practice Address - Fax:503-769-9530
Is Sole Proprietor?:No
Enumeration Date:2010-05-13
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY43867207V00000X
ORMD215626207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100131400Medicaid
KYP00947909OtherRR MEDICARE
OR500822477Medicaid