Healthcare Provider Details

I. General information

NPI: 1417866468
Provider Name (Legal Business Name): DANE JOSHUA WAGNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 COMMERCE ST
TACOMA WA
98402-3112
US

IV. Provider business mailing address

1900 COMMERCE ST
TACOMA WA
98402-3112
US

V. Phone/Fax

Practice location:
  • Phone: 253-692-4400
  • Fax:
Mailing address:
  • Phone: 253-692-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: