Healthcare Provider Details

I. General information

NPI: 1407618739
Provider Name (Legal Business Name): DEVON WAGNER APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2024
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5708 E. LAKE SAMMANISH PKWY SE
ISSAQUAH WA
98029
US

IV. Provider business mailing address

5708 E. LAKE SAMMANISH PKWY SE
ISSAQUAH WA
98029
US

V. Phone/Fax

Practice location:
  • Phone: 425-688-5777
  • Fax:
Mailing address:
  • Phone: 425-688-5777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAP61598671
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number60929310
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: