Healthcare Provider Details

I. General information

NPI: 1851074959
Provider Name (Legal Business Name): EMMA WAGNER FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2023
Last Update Date: 08/08/2023
Certification Date: 08/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10345 WATSON RD
SAINT LOUIS MO
63127-1105
US

IV. Provider business mailing address

10345 WATSON RD
SAINT LOUIS MO
63127-1105
US

V. Phone/Fax

Practice location:
  • Phone: 314-965-6033
  • Fax: 314-965-6067
Mailing address:
  • Phone: 314-965-6033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number20232032275
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: