Provider Demographics
NPI:1952824211
Name:WAGONER, PETER STEVEN (OD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:STEVEN
Last Name:WAGONER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8127 W GRANDRIDGE BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7166
Mailing Address - Country:US
Mailing Address - Phone:509-783-8383
Mailing Address - Fax:509-735-2592
Practice Address - Street 1:8127 W GRANDRIDGE BLVD STE 110
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7166
Practice Address - Country:US
Practice Address - Phone:509-783-8383
Practice Address - Fax:509-735-2592
Is Sole Proprietor?:No
Enumeration Date:2017-07-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60770099152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist