1720174931 NPI number — MS. SARAH C WAGNER PA-C

Table of content: MS. SARAH C WAGNER PA-C (NPI 1720174931)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720174931 NPI number — MS. SARAH C WAGNER PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAGNER
Provider First Name:
SARAH
Provider Middle Name:
C
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720174931
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/18/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 47
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILL CITY
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97360-0047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-897-4100
Provider Business Mailing Address Fax Number:
503-897-2673

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
280 S 1ST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILL CITY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97360-2324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-897-4100
Provider Business Practice Location Address Fax Number:
503-897-2673
Provider Enumeration Date:
10/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  99 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA161499 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: 3110 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 500657211 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: R01271179 . This is a "RAILROAD MEDICARE - PH&S" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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