Provider Demographics
NPI:1861450314
Name:WAGENECK, ROBERT ALLAN (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:ALLAN
Last Name:WAGENECK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 S 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3550
Mailing Address - Country:US
Mailing Address - Phone:509-853-1082
Mailing Address - Fax:509-573-6275
Practice Address - Street 1:521 E MOUNTAIN VIEW AVE
Practice Address - Street 2:
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-3865
Practice Address - Country:US
Practice Address - Phone:509-962-1414
Practice Address - Fax:509-962-1408
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN2875207Q00000X
WAOP60971885207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2142124Medicaid
WA414072OtherLABOR AND INDUSTRIES
WA414072OtherLABOR AND INDUSTRIES
TX8L12215Medicare PIN