Healthcare Provider Details

I. General information

NPI: 1063524387
Provider Name (Legal Business Name): DR. STEPHEN R WAGNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 11/24/2025
Certification Date: 11/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 SMITH AVE N
SAINT PAUL MN
55102-2344
US

IV. Provider business mailing address

8681 EAGLE POINT BLVD
LAKE ELMO MN
55042-8628
US

V. Phone/Fax

Practice location:
  • Phone: 651-735-0501
  • Fax: 651-735-1870
Mailing address:
  • Phone: 651-251-8021
  • Fax: 651-251-8050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number35533
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number35533
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number35533
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: