Provider Demographics
NPI:1497797120
Name:WAGONER, JAMES (LMP)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:WAGONER
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5210 CORPORATE CENTER LOOP SE
Mailing Address - Street 2:SUITE D
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-5952
Mailing Address - Country:US
Mailing Address - Phone:360-455-8155
Mailing Address - Fax:360-455-1655
Practice Address - Street 1:1800 COOPER POINT RD SW
Practice Address - Street 2:#21
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-1178
Practice Address - Country:US
Practice Address - Phone:360-956-1100
Practice Address - Fax:360-956-1113
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0211977OtherDEPT. OF LABOR & INDUSTRY
WA6619WAOtherREGENCE BLUE SHIELD
WA8947908OtherL&I CRIME VICTIMS