Provider Demographics
NPI:1871020933
Name:SEATTLE SPORTS & REGENERATIVE MEDICINE PLLC
Entity Type:Organization
Organization Name:SEATTLE SPORTS & REGENERATIVE MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:206-999-8556
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:206-486-7837
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:206-999-8556
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-18
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00022633207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty