Provider Demographics
NPI:1831424365
Name:WAGNER, AARON EUGENE (MD)
Entity type:Individual
Prefix:
First Name:AARON
Middle Name:EUGENE
Last Name:WAGNER
Suffix:
Gender:M
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:PO BOX 3868
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99220-3868
Mailing Address - Country:US
Mailing Address - Phone:509-228-1000
Mailing Address - Fax:509-252-9300
Practice Address - Street 1:700 W IRONWOOD DR
Practice Address - Street 2:STE130
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2656
Practice Address - Country:US
Practice Address - Phone:509-228-1000
Practice Address - Fax:509-252-9300
Is Sole Proprietor?:No
Enumeration Date:2009-10-16
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD604520092085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8929157Medicare PIN
ID20006371Medicare PIN