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General NPI Number Information
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NPI Number | 1235457359
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Entity Type | Individual
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Provider Name | AMANDA ELLEN WAGNER MD
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Gender | Female
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Dates
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Enumeration Date | 05/13/2010
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Last Update Date | 10/17/2023
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Provider Practice Location Address
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Address Line | 1373 N 10TH AVE
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City | STAYTON
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State | OR
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Zip | 97383-2037
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Country | US
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Telephone | 503-769-9522
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Fax | 503-769-9530
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Provider Business Mailing Address
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Address Line | PO BOX 577
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City | STAYTON
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State | OR
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Zip | 97383-0577
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Country | US
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Telephone | 503-769-2175
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Fax | 503-769-3472
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | 43867
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | MD215626
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License Number State | OR
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