Provider Demographics
NPI:1720774177
Name:WAGNER, ZACKERY ROBERT
Entity Type:Individual
Prefix:
First Name:ZACKERY
Middle Name:ROBERT
Last Name:WAGNER
Suffix:
Gender:M
Credentials:
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 1287
Mailing Address - Street 2:
Mailing Address - City:BUCKLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98321-1287
Mailing Address - Country:US
Mailing Address - Phone:360-761-9516
Mailing Address - Fax:
Practice Address - Street 1:2323 JENSEN ST
Practice Address - Street 2:
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-3605
Practice Address - Country:US
Practice Address - Phone:360-825-2541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-17
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANA61270089376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide