Individual
AMANDA ELLEN WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
1373 N 10TH AVE, STAYTON, OR 97383-2037
(503) 769-9522
(503) 769-9530
Mailing address
PO BOX 577, STAYTON, OR 97383-0577
(503) 769-2175
(503) 769-3472
Taxonomy
Speciality
Code
Description
License number
State
207V00000X
Obstetrics & Gynecology Physician
43867
KY
207V00000X
Obstetrics & Gynecology Physician
Primary
MD215626
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
500822477
—
OR
05
—
7100131400
—
KY
01
—
P00947909
RR MEDICARE
KY
Enumeration date
05/13/2010
Last updated
10/17/2023
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