=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528228103
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JARED PAUL WAGNER M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2008
-----------------------------------------------------
Last Update Date | 01/18/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 636 VALLEY MALL PKWY STE 5
-----------------------------------------------------
City | WENATCHEE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98802-4898
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-362-9889
-----------------------------------------------------
Fax | 509-888-7428
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 636 VALLEY MALL PKWY STE 5
-----------------------------------------------------
City | E WENATCHEE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98802-4898
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-888-3496
-----------------------------------------------------
Fax | 509-888-7428
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number | MD60717768
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------