Individual
JAMES EVERETT WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
BS, QMHA
Contact information
Practice address
1175 E MAIN ST STE 1C, MEDFORD, OR 97504-7457
(541) 772-0127
Mailing address
715 SW RAMSEY AVE, GRANTS PASS, OR 97527-5500
(541) 474-5579
Taxonomy
Speciality
Code
Description
License number
State
175T00000X
Peer Specialist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1952842346
—
OR
Enumeration date
03/17/2017
Last updated
02/26/2018
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