Healthcare Provider Details

I. General information

NPI: 1144428038
Provider Name (Legal Business Name): COREY ALLEN WAGNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 06/18/2021
Certification Date: 06/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S NEW BALLAS RD SUITE 499-A
SAINT LOUIS MO
63141-8232
US

IV. Provider business mailing address

621 S NEW BALLAS RD SUITE 499-A
SAINT LOUIS MO
63141-8232
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-7650
  • Fax:
Mailing address:
  • Phone: 314-251-7650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number259975-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2010020901
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number2010020901
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: