Healthcare Provider Details

I. General information

NPI: 1497397616
Provider Name (Legal Business Name): MARY BETH WAGNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2019
Last Update Date: 10/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 EXECUTIVE PKWY STE 220
EUGENE OR
97401-7109
US

IV. Provider business mailing address

1400 EXECUTIVE PKWY STE 220
EUGENE OR
97401-7109
US

V. Phone/Fax

Practice location:
  • Phone: 541-345-1669
  • Fax: 541-359-2238
Mailing address:
  • Phone: 541-345-1669
  • Fax: 541-359-2238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number25074
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: