Provider Demographics
NPI:1891918629
Name:WAGNER, DRUE O (MD)
Entity Type:Individual
Prefix:DR
First Name:DRUE
Middle Name:O
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:825 SE BISHOP BLVD
Mailing Address - Street 2:STE 901
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-5538
Mailing Address - Country:US
Mailing Address - Phone:208-892-1346
Mailing Address - Fax:208-892-8306
Practice Address - Street 1:619 S WASHINGTON ST
Practice Address - Street 2:SUITE 203
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-3090
Practice Address - Country:US
Practice Address - Phone:208-892-1346
Practice Address - Fax:208-892-8306
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2019-02-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WA00028927207Q00000X
IDM-11013207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1008218020002Medicaid
PA1008218020002Medicaid
PA0712Medicare ID - Type Unspecified