Provider Demographics
NPI:1649211764
Name:WAGNER, MARK DAVID (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DAVID
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 DEXTER AVE N STE 320
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98109-4878
Mailing Address - Country:US
Mailing Address - Phone:206-620-0333
Mailing Address - Fax:206-462-7520
Practice Address - Street 1:1000 DEXTER AVE N STE 320
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-4878
Practice Address - Country:US
Practice Address - Phone:206-620-0333
Practice Address - Fax:206-462-7520
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00022633207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA378219OtherLABOR AND INDUSTRY
WA1060045Medicaid