Provider Demographics
NPI:1487627550
Name:WAGONER, CATHERINE YH (MD)
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:YH
Last Name:WAGONER
Suffix:
Gender:F
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:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9290 SE SUNNYBROOK BLVD STE 120
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-6802
Practice Address - Country:US
Practice Address - Phone:503-215-2110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9839208000000X
ORMD171324208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002016768Medicaid
NV002016768Medicaid
NVH42514Medicare UPIN
NV35131Medicare ID - Type Unspecified
NV370019196OtherRAILROAD MEDICARE