Provider Demographics
NPI:1871567941
Name:WAGNER, WILLIAM D (DO)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:D
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 W TIETAN ST
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-4445
Mailing Address - Country:US
Mailing Address - Phone:509-525-3720
Mailing Address - Fax:509-522-1592
Practice Address - Street 1:55 W TIETAN ST
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-4445
Practice Address - Country:US
Practice Address - Phone:509-525-3720
Practice Address - Fax:509-522-1592
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001866207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA170959OtherL&I
WA8352478Medicaid
WAP00002021OtherRAIL ROAD MEDICARE
OR227270Medicaid
WA170959OtherL&I
WAH79139Medicare UPIN