Provider Demographics
NPI:1730298647
Name:WAGNER, ROBERT BASTIAN (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:BASTIAN
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 1:22490 SW MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-9619
Mailing Address - Country:US
Mailing Address - Phone:503-638-8218
Mailing Address - Fax:503-638-9698
Practice Address - Street 1:22490 SW MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-9619
Practice Address - Country:US
Practice Address - Phone:503-638-8218
Practice Address - Fax:503-638-9698
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD08471207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR214510Medicaid
ORR101876Medicare PIN
OR214510Medicaid