Provider Demographics
NPI:1023552114
Name:WAGNER, JEFFREY DAVID (DNP, ARNP)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:DAVID
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DNP, ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 SW BOND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4501
Mailing Address - Country:US
Mailing Address - Phone:503-418-9400
Mailing Address - Fax:503-418-9401
Practice Address - Street 1:3303 SW BOND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239
Practice Address - Country:US
Practice Address - Phone:503-418-9400
Practice Address - Fax:503-418-9401
Is Sole Proprietor?:No
Enumeration Date:2016-12-08
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201801605NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily