Provider Demographics
NPI:1982115358
Name:WAGNER, VITAS ERIK (MD)
Entity type:Individual
Prefix:
First Name:VITAS
Middle Name:ERIK
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 1:1708 YAKIMA AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-5300
Mailing Address - Country:US
Mailing Address - Phone:253-552-1200
Mailing Address - Fax:253-552-1239
Practice Address - Street 1:1708 YAKIMA AVE STE 105
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-5300
Practice Address - Country:US
Practice Address - Phone:253-552-1200
Practice Address - Fax:253-552-1239
Is Sole Proprietor?:No
Enumeration Date:2017-10-12
Last Update Date:2025-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61176219208600000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2189171Medicaid