Healthcare Provider Details

I. General information

NPI: 1649211764
Provider Name (Legal Business Name): MARK DAVID WAGNER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 05/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 DEXTER AVE N STE 320
SEATTLE WA
98109-4878
US

IV. Provider business mailing address

1000 DEXTER AVE N STE 320
SEATTLE WA
98109-4878
US

V. Phone/Fax

Practice location:
  • Phone: 206-620-0333
  • Fax: 206-462-7520
Mailing address:
  • Phone: 206-620-0333
  • Fax: 206-462-7520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberMD00022633
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: