Provider Demographics
NPI:1992022230
Name:WAGNER, JENNIFER A (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4420 76TH ST NE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-3726
Mailing Address - Country:US
Mailing Address - Phone:360-651-7490
Mailing Address - Fax:
Practice Address - Street 1:4420 76TH ST NE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-3726
Practice Address - Country:US
Practice Address - Phone:360-651-7490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-27
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-39770208000000X
NE26711208000000X
MO2017024333208000000X
390200000X
WAMD61398282208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program