Provider Demographics
NPI:1245557198
Name:WAGNER, CLIFFORD WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:WILLIAM
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9120 NE VANCOUVER MALL LOOP
Mailing Address - Street 2:SUITE 230
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-6353
Mailing Address - Country:US
Mailing Address - Phone:360-896-9393
Mailing Address - Fax:360-896-0878
Practice Address - Street 1:9120 NE VANCOUVER MALL LOOP
Practice Address - Street 2:SUITE 230
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-6353
Practice Address - Country:US
Practice Address - Phone:360-896-9393
Practice Address - Fax:360-896-0878
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-30
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00032505207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine