Basic Information
| Provider Information | |||||||||
| NPI: | 1982840526 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | SARA | ||||||||
| MiddleName: | JAGELS | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1793 13TH ST SE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973022541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033628385 | ||||||||
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| Practice Location | |||||||||
| Address1: | 700 S 320TH ST STE A | ||||||||
| Address2: | |||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980034691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042732717 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2009 | ||||||||
| LastUpdateDate: | 06/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA 9103621 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 2141807 | 05 | WA | MEDICAID |