Healthcare Provider Details

I. General information

NPI: 1356555742
Provider Name (Legal Business Name): LAURA L. WAGNER APRN, BC, APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 12/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2810 CROSSROADS DR
MADISON WI
53718-7942
US

IV. Provider business mailing address

2810 CROSSROADS DR
MADISON WI
53718-7942
US

V. Phone/Fax

Practice location:
  • Phone: 608-819-0033
  • Fax: 608-819-0048
Mailing address:
  • Phone: 608-819-0033
  • Fax: 608-819-0048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number1352-033
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: