Provider Demographics
NPI:1427040203
Name:WAGNER, MARY K (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:K
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1414 N VERCLER RD
Mailing Address - Street 2:BUILDING 1
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216-1092
Mailing Address - Country:US
Mailing Address - Phone:509-928-6383
Mailing Address - Fax:509-926-9420
Practice Address - Street 1:1414 N VERCLER RD
Practice Address - Street 2:BUILDING 1
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1092
Practice Address - Country:US
Practice Address - Phone:509-928-6383
Practice Address - Fax:509-926-9420
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60167561208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
D34284Medicare UPIN
105274Medicare ID - Type Unspecified