Provider Demographics
NPI:1407951668
Name:WAGNON, SCOTT EDWARD (PA-C)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:EDWARD
Last Name:WAGNON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1655 S. ELM ST. #207
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:OR
Mailing Address - Zip Code:97013-3960
Mailing Address - Country:US
Mailing Address - Phone:503-260-5433
Mailing Address - Fax:
Practice Address - Street 1:2830 CRESCENT AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97408-7397
Practice Address - Country:US
Practice Address - Phone:541-686-9000
Practice Address - Fax:541-242-4585
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2015-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01088363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical