Provider Demographics
NPI:1295775427
Name:WAGAR, WESLEY ALLEN (PA-C)
Entity type:Individual
Prefix:MR
First Name:WESLEY
Middle Name:ALLEN
Last Name:WAGAR
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 S AUBURN ST
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-5665
Mailing Address - Country:US
Mailing Address - Phone:509-586-2828
Mailing Address - Fax:509-586-2525
Practice Address - Street 1:711 S AUBURN ST
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-5665
Practice Address - Country:US
Practice Address - Phone:509-586-2828
Practice Address - Fax:509-586-2525
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01111363AS0400X
WAPA10004591363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8381717Medicaid
Q05774Medicare UPIN
WA8381717Medicaid