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General NPI Number Information
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NPI Number | 1891918629
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Entity Type | Individual
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Provider Name | DRUE O. WAGNER M.D.
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Gender | Male
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Dates
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Enumeration Date | 04/10/2007
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Last Update Date | 02/04/2019
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Provider Practice Location Address
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Address Line | 619 S WASHINGTON ST SUITE 203
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City | MOSCOW
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State | ID
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Zip | 83843-3090
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Country | US
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Telephone | 208-892-1346
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Fax | 208-892-8306
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Provider Business Mailing Address
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Address Line | 825 SE BISHOP BLVD STE 901
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City | PULLMAN
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State | WA
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Zip | 99163-5538
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Country | US
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Telephone | 208-892-1346
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Fax | 208-892-8306
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 00028927
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | M-11013
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License Number State | ID
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