Provider Demographics
NPI:1477160737
Name:WAGNER, MEGHAN ANNE (MSN, ARNP)
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:ANNE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MSN, ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16714 E LAKE GOODWIN RD
Mailing Address - Street 2:
Mailing Address - City:STANWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98292-7778
Mailing Address - Country:US
Mailing Address - Phone:360-421-8259
Mailing Address - Fax:
Practice Address - Street 1:16714 E LAKE GOODWIN RD
Practice Address - Street 2:
Practice Address - City:STANWOOD
Practice Address - State:WA
Practice Address - Zip Code:98292-7778
Practice Address - Country:US
Practice Address - Phone:360-421-8259
Practice Address - Fax:360-838-4990
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-29
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61143462363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty