Healthcare Provider Details

I. General information

NPI: 1265049779
Provider Name (Legal Business Name): ANDREA LOUISE WAGNER MED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANDREA WAGNER MED

II. Dates (important events)

Enumeration Date: 09/29/2020
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1052 OAK FOREST DR STE 190
ONALASKA WI
54650-3705
US

IV. Provider business mailing address

1351 ANNAPOLIS DR
HOLMEN WI
54636-6408
US

V. Phone/Fax

Practice location:
  • Phone: 507-884-1497
  • Fax:
Mailing address:
  • Phone: 507-884-1497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number02206
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number11724-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: