Provider Demographics
NPI:1710989785
Name:WAGNER, MARC ANTHONY (MD)
Entity Type:Individual
Prefix:MR
First Name:MARC
Middle Name:ANTHONY
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2200 NE NEFF RD
Mailing Address - Street 2:STE 200
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4283
Mailing Address - Country:US
Mailing Address - Phone:541-382-3344
Mailing Address - Fax:541-382-1681
Practice Address - Street 1:2200 NE NEFF RD
Practice Address - Street 2:STE 200
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4283
Practice Address - Country:US
Practice Address - Phone:541-382-3344
Practice Address - Fax:541-382-1681
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD25280208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation