| Doctor Name: | BLAKE JOSEPH WAGNER |
| NPI Number: | 1134267735 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | D.C. |
| License Number: | CH00003095 |
| Business Practice Address: | 21505 Market Pl Nw Suite 102 Poulsbo, WA - 983706635 |
| Business Phone Number: | 3605983143 |
| Business Fax Number: | 3605984172 |
| Mailing Address: | 21505 Market Place Nw, Suite 102 POULSBO |
| State: | WA |
| Postal Code: | 98370 |
| Phone Number: | 3605983143 |
| Fax Number: | 3605984172 |
| NPI Enumeration Date: | 02/03/2007 |
| NPI Last Update Date: | 04/25/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 111N00000X |
| License Number: | CH00003095 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WA |
| Taxonomy Type: | Chiropractic Providers |
| Taxonomy Classification: | Chiropractor |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A provider qualified by a Doctor of Chiropractic (D.C.), licensed by the State and who practices chiropractic medicine -that discipline within the healing arts which deals with the nervous system and its relationship to the spinal column and its interrelationship with other body systems. |