Basic Information
| Provider Information | |||||||||
| NPI: | 1548208234 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | RACHEL | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WANNE | ||||||||
| OtherFirstName: | RACHEL | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 873 HINOTES CT | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | LYNDEN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982649043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603189705 | ||||||||
| FaxNumber: | 3603188735 | ||||||||
| Practice Location | |||||||||
| Address1: | 2220 CORNWALL AVE | ||||||||
| Address2: | |||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982253719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607522865 | ||||||||
| FaxNumber: | 3606478093 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD00045321 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8436636 | 05 | WA | MEDICAID | 8926939 | 01 | WA | LABOR & INDUSTRIES (CV) | OTHER | 0201489 | 01 | WA | LABOR & INDUSTRIES (REG) | OTHER | 3970WA | 01 | WA | REGENCE BLUESHIELD | OTHER |