Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0208X | Pediatric Infectious Diseases | MD00044528 | WA |
NPI | 1447333521 |
---|---|
Provider Name | Thor Wagner |
First Address | Seattle, WA 98195-6340 |
Second Address | Seattle, WA 98195-6340 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/10/2006 |
Last Update Date | 08/07/2007 |