Provider Demographics
NPI:1811921638
Name:WAGNER, MICHAEL L (DC)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:L
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9615 LEVIN RD NW
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-7666
Mailing Address - Country:US
Mailing Address - Phone:360-692-3800
Mailing Address - Fax:360-692-3700
Practice Address - Street 1:9615 LEVIN RD NW
Practice Address - Street 2:SUITE 100
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-7666
Practice Address - Country:US
Practice Address - Phone:360-692-3800
Practice Address - Fax:360-692-3700
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003618111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB29218Medicare ID - Type Unspecified