Healthcare Provider Details

I. General information

NPI: 1235457359
Provider Name (Legal Business Name): AMANDA ELLEN WAGNER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2010
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1373 N 10TH AVE
STAYTON OR
97383-2037
US

IV. Provider business mailing address

PO BOX 577
STAYTON OR
97383-0577
US

V. Phone/Fax

Practice location:
  • Phone: 503-769-9522
  • Fax: 503-769-9530
Mailing address:
  • Phone: 503-769-2175
  • Fax: 503-769-3472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number43867
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD215626
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: