Basic Information
Provider Information | |||||||||
NPI: | 1497797120 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WAGONER | ||||||||
FirstName: | JAMES | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5210 CORPORATE CENTER LOOP SE | ||||||||
Address2: | SUITE D | ||||||||
City: | LACEY | ||||||||
State: | WA | ||||||||
PostalCode: | 985035952 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3604558155 | ||||||||
FaxNumber: | 3604551655 | ||||||||
Practice Location | |||||||||
Address1: | 1800 COOPER POINT RD SW | ||||||||
Address2: | #21 | ||||||||
City: | OLYMPIA | ||||||||
State: | WA | ||||||||
PostalCode: | 985021178 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3609561100 | ||||||||
FaxNumber: | 3609561113 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/10/2006 | ||||||||
LastUpdateDate: | 01/16/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X |   |   | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 0211977 | 01 | WA | DEPT. OF LABOR & INDUSTRY | OTHER | 6619WA | 01 | WA | REGENCE BLUE SHIELD | OTHER | 8947908 | 01 | WA | L&I CRIME VICTIMS | OTHER |