Basic Information
| Provider Information | |||||||||
| NPI: | 1861587305 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGONER | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5096 | ||||||||
| Address2: | |||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982275096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607382200 | ||||||||
| FaxNumber: | 3607525687 | ||||||||
| Practice Location | |||||||||
| Address1: | 3015 SQUALICUM PKWY | ||||||||
| Address2: | |||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982251945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607382200 | ||||||||
| FaxNumber: | 3607525687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 11/19/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 12538 | ME | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | MD00018942 | WA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 0244685 | 01 | WA | L&I AND CRIME VICTIMS | OTHER | 5196237 | 01 | WA | AETAN | OTHER | 8532970 | 05 | WA | MEDICAID | 001047 | 01 | ME | ANTHEM | OTHER | 1861587305 | 05 | WA | MEDICAID | 315910099 | 05 | ME | MEDICAID | 3296WA | 01 | WA | REGENCE | OTHER | 1699860270 | 01 | ME | GROUP NPI # | OTHER | 010212444 | 01 | ME | TAX ID # | OTHER | MM9730 | 01 | ME | MEDICARE GROUP # | OTHER | 1861587305 | 01 | ME | INDIVIDUAL NPI # | OTHER |