Individual
DR. MARK BASTIAN WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
15755 SW SEQUOIA PKWY, SUITE 200, TIGARD, OR 97224-7166
(503) 639-6002
(503) 639-1403
Mailing address
15755 SW SEQUOIA PKWY, SUITE 200, TIGARD, OR 97224-7166
(503) 639-6002
(503) 639-1403
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
MD26810
OR
207X00000X
Orthopaedic Surgery Physician
Primary
MD26810
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
006033
—
OR
01
—
1891710869
NPI
OR
01
—
93-1280904
TAX ID
OR
Enumeration date
07/12/2006
Last updated
04/07/2015
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