Provider Demographics
NPI:1508237314
Name:WAGNER, LINDSAY (DC)
Entity Type:Individual
Prefix:DR
First Name:LINDSAY
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3706 RIVERS EDGE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-7426
Mailing Address - Country:US
Mailing Address - Phone:503-734-7124
Mailing Address - Fax:
Practice Address - Street 1:1821 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5618
Practice Address - Country:US
Practice Address - Phone:310-829-7339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-20
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5686111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR5686OtherOREGON BOARD OF CHIROPRACTIC EXAMINERS