Healthcare Provider Details

I. General information

NPI: 1811077894
Provider Name (Legal Business Name): THEODORE A WAGNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 09/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UWMC-ROOSEVELT 4245 ROOSEVELT WAY NE
SEATTLE WA
98105-4740
US

IV. Provider business mailing address

PO BOX 50095
SEATTLE WA
98145-5095
US

V. Phone/Fax

Practice location:
  • Phone: 206-598-4288
  • Fax:
Mailing address:
  • Phone: 206-543-6420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD00011315
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License NumberMD00011315
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberMD00011315
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: