Healthcare Provider Details

I. General information

NPI: 1396103032
Provider Name (Legal Business Name): MICHELE E WAGNER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2016
Last Update Date: 01/08/2020
Certification Date: 01/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3927 RUCKER AVE
EVERETT WA
98201-4833
US

IV. Provider business mailing address

PO BOX 5127
EVERETT WA
98206-5127
US

V. Phone/Fax

Practice location:
  • Phone: 425-339-5447
  • Fax: 425-259-1185
Mailing address:
  • Phone: 425-339-5447
  • Fax: 425-259-1185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number019459
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMW5580281
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: