Provider Demographics
NPI:1891710869
Name:WAGNER, MARK BASTIAN (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:BASTIAN
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15755 SW SEQUOIA PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7166
Mailing Address - Country:US
Mailing Address - Phone:503-639-6002
Mailing Address - Fax:503-639-1403
Practice Address - Street 1:15755 SW SEQUOIA PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-7166
Practice Address - Country:US
Practice Address - Phone:503-639-6002
Practice Address - Fax:503-639-1403
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD26810174400000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR006033Medicaid
OR93-1280904OtherTAX ID
OR1891710869OtherNPI
OR93-1280904OtherTAX ID
ORI58815Medicare UPIN
OR006033Medicaid