Active NPI
Amy W Wagner, PH.D.
- Psychologist
- Portland, OR
National Provider Identifier
1003827965
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Psychologist
- License
- 2491
- Practice address
- 3710 SW US Veterans Hospital Rd
V3-Satp
Portland, OR 97239-2964 - Phone
- (503) 220-8262
- Fax
- (360) 737-1419
- NPI assigned
- Aug 10, 2006
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychologist | 103T00000X | 2491 | WA | Primary |
Addresses
Primary practice location
3710 SW US Veterans Hospital Rd
V3-Satp
Portland, OR 97239-2964
Mailing address
4205 NW Spruce St
Vancouver, WA 98660-1655
Phone (360) 750-0506
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Opted out of Medicare
- Yes, effective Sep 4, 2025 through Sep 4, 2027
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2491 | WA | MD | Psychologist |
| 601 | WA | MD | Clinical Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1155168000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1003827965",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4205 NW SPRUCE ST",
"city": "VANCOUVER",
"state": "WA",
"postal_code": "986601655",
"telephone_number": "360-750-0506"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3710 SW US VETERANS HOSPITAL RD",
"address_2": "V3-SATP",
"city": "PORTLAND",
"state": "OR",
"postal_code": "972392964",
"telephone_number": "503-220-8262",
"fax_number": "360-737-1419"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WAGNER",
"first_name": "AMY",
"middle_name": "W",
"name_prefix": "Dr.",
"credential": "PH.D.",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-08-10",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "103T00000X",
"taxonomy_group": "",
"desc": "Psychologist",
"state": "WA",
"license": "2491",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Portland, OR
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.