Provider Demographics
NPI:1598651192
Name:WAGNER, LAUREN
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2335 OSWEGO GLEN CT
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-1548
Mailing Address - Country:US
Mailing Address - Phone:503-593-2613
Mailing Address - Fax:
Practice Address - Street 1:1220 W POPLAR ST STE A
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2757
Practice Address - Country:US
Practice Address - Phone:503-593-2613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-18
Last Update Date:2025-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14223358-24012251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic