Provider Demographics
NPI:1720174931
Name:WAGNER, SARAH C (PA-C)
Entity Type:Individual
Prefix:MS
First Name:SARAH
Middle Name:C
Last Name:WAGNER
Suffix:
Gender:F
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:PO BOX 47
Mailing Address - Street 2:
Mailing Address - City:MILL CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97360-0047
Mailing Address - Country:US
Mailing Address - Phone:503-897-4100
Mailing Address - Fax:503-897-2673
Practice Address - Street 1:280 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:MILL CITY
Practice Address - State:OR
Practice Address - Zip Code:97360-2324
Practice Address - Country:US
Practice Address - Phone:503-897-4100
Practice Address - Fax:503-897-2673
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT99363A00000X
ORPA161499363A00000X
AZ3110363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500657211Medicaid
ORR01271179OtherRAILROAD MEDICARE - PH&S
OR500657211Medicaid
ORR170014Medicare PIN