MEDICARE: MRS. KAREN KAYE WAGNER LMP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	MA00015471	WA

General Provider Information

NPI Number	:	1699823187
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KAREN KAYE WAGNER LMP

Provider Business Mailing Address
First Line	:	1309 NE 103RD CT
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98664-4307
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7904 NE 6TH AVE
Second Line	:	SUITE C
City	:	VANCOUVER
State	:	WA
Zip	:	98665-8150
Country	:	US
Telephone Number	:	360-690-4114
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/08/2007
Last Update Date	:	07/08/2007

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