Healthcare Provider Details

I. General information

NPI: 1215329420
Provider Name (Legal Business Name): JASON WAGNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2015
Last Update Date: 02/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2405 28TH ST
ANACORTES WA
98221-2484
US

IV. Provider business mailing address

2405 28TH ST
ANACORTES WA
98221-2484
US

V. Phone/Fax

Practice location:
  • Phone: 360-333-5684
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: